Angiogram procedure note template
Coronary anatomy recorded vessel by vessel.
- Indication
- Presenting complaint, ischaemia evaluation, angiography after infarct, or pre-operative workup.
- Access
- Radial or femoral, the side, and the sheath size.
- Findings
- One line each for LMS, LAD, LCx and RCA, then dominance.
- Procedure
- Vessels imaged, views obtained and contrast volume.
- Complications
- None, or the complication and how it was managed.
- Impression
- Coronary anatomy and disease severity.
- Plan
- Conservative management, further intervention or surgical referral, medications and follow-up.
Worked examples
Angiogram · single vessel disease Reid, Malcolm · 61M · Synthetic patient
Indication Exertional chest pain with an abnormal stress test. Access Right radial artery, 6F sheath. Findings LMS normal. LAD: 60% mid vessel stenosis. LCx unobstructed. RCA unobstructed. Right dominant. Procedure Standard views of both systems. Pressure wire to mid LAD: FFR 0.84. Contrast 110 mL. Complications None. Haemostasis achieved with a radial band. Impression Moderate mid LAD stenosis, not haemodynamically significant (FFR 0.84). Plan Medical therapy. Review in rooms in 6 weeks.
Angiogram · after inferior infarct Tran, Kevin · 56M · Synthetic patient
Indication Inferior myocardial infarction, angiography on the day after thrombolysis. Access Right femoral artery, 6F sheath. Findings LMS normal. LAD mild irregularity. LCx: 70% stenosis of OM1. RCA: mid vessel occlusion, TIMI 1 flow. Right dominant. Procedure PCI to mid RCA: 3.5 × 28 mm DES, TIMI 3 flow restored. Contrast 160 mL. Complications Transient bradycardia on reperfusion, settled without atropine. Impression Culprit mid RCA occlusion, treated. Bystander circumflex disease. Plan Aspirin 100 mg and clopidogrel 75 mg daily for 12 months. Atorvastatin 80 mg. Staged assessment of the OM1 lesion. Cardiac rehabilitation referral.
Angiogram · unobstructed coronaries Sinclair, Nadia · 52F · Synthetic patient
Indication Atypical chest pain with a calcium score of 180 and a non-diagnostic CT coronary angiogram. Access Left radial artery, 5F sheath. Findings LMS normal. LAD normal, myocardial bridge in the mid vessel. LCx normal. Left dominant. Small non-dominant RCA, normal. Procedure Standard views. Contrast 60 mL. Radial cocktail given, no spasm. Complications Nil. Impression Unobstructed coronary arteries. Incidental mid LAD myocardial bridge. Plan Cease antianginal therapy. Start atorvastatin 40 mg for CAC 180. Non-cardiac causes of the pain to be investigated by the GP. No further coronary imaging planned. Disposition Day case. Discharge 4 h post procedure if the radial site is settled.
