Rating the urgency of coronary angiography: results of an expert panel process

Objective — To rate the urgency of coronary angiography for patients with ischemic heart disease. Ratings were made for patients with varying degrees of symptoms and noninvasive cardiac test results.

Design — A panel of 10 cardiologists rated 354 case scenarios which presented varying combinations of clinical factors that may affect urgency.

Measurements — The case scenarios were rated by each panelist on a waiting time scale consisting of six categories which ranged from the requirement for emergency angiography to a delay of up to three months. A seventh category represented the lack of urgent need for angiography. The contribution of each clinical factor to urgency of coronary angiography was determined.

Main Results — Symptom class as defined by a modification to the Canadian Cardiovascular Society grading scale for angina pectoris, results of exercise stress tests and results of imaging studies were the major determinants of urgency. In cases of unstable angina, rest electrocardiography is of importance. These factors explained at least 95% of the variance in the case urgency scores. There was agreement by at least five of the panelists on urgency score in 84% of cases. The assigned urgency varied from 6.7, representing no urgent need for angiography, for minimally asymptomatic angina with no positive noninvasive test results, to immediate angiography for cardiogenic shock. Other factors had minimal or negligible effects on urgency.

Conclusions — The urgency of need for coronary angiography was addressed by an explicit method incorporating the judgements of a panel of expert cardiologists, permitting derivation of a scoring system for rating priority of individual patients in the face of waiting lists. These methods illustrate an approach to problems presented by procedure waiting lists.