Garland lecture. Coronary arteriography: pathologic and prognostic implications

Coronary arteriography is properly considered the in vivo "gold standard" by which all other clinical diagnostic criteria and noninvasive tests of coronary disease are gauged. In most respects, the radiographic-morphologic findings of the coronary arteriogram are readily translated into the pathologic substrate of disease. Careful correlative studies suggest, however, that in an important group of patients the arteriogram underpredicts the degree of disease, and in a far smaller group it overpredicts. Furthermore, there is no "one" correct interpretation of the coronary arteriogram; there are striking inter- and intraindividual variations in the assessment of the degree of stenosis when experts evaluate the examinations. Despite the discrepancies in angiographic-pathologic correlation and in multiple observer analysis, coronary arteriography in its present form represents an important predictive element in assessing the prognosis for the patient with coronary disease. The distribution and degree of the lesions per se are important prognostic factors, but these take on additional force in the presence of asynergy, cardiac enlargement, congestive heart failure, or depressed ejection fraction, all of which worsen the prognosis significantly.