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The fact that allograft coronary arteriopathy is frequent and has a poor prognosis means early diagnosis is critical. Furthermore, because of important distinctions between native heart coronary artery disease and allograft arteriopathy, standard noninvasive diagnostic tests seem less sensitive and specific. Assuming that coronary angiography is the optimal method for detection and staging of allograft arteriopathy, one must establish the point at which an initial study should be performed and the incidence of abnormalities in donor hearts. Review of perioperative coronary angiograms in 75 consecutive patients undergoing heart transplantation (within 8 weeks) demonstrated that only six hearts had coronary artery abnormalities: two had focal coronary artery disease, one had an anomalous circumflex coronary artery, and three had nonobstructive calcification of the coronary arteries. To determine if serial quantitative angiography was helpful in detecting progression of coronary disease during a 12-month period, 28 patients underwent baseline and repeat quantification of mean luminal diameter of predetermined segments of the mid and distal portions of the left anterior descending artery. No patient had identifiable disease on the first angiogram, and 12 were studied in the first year of their transplants. During the interval, mean mid left anterior descending coronary diameter was 3.17 +/- 0.6 mm on the first study and 3.06 +/- 0.7 on the second study. Visual assessment of the angiograms, however, identified allograft arteriopathy when two studies were available for inspection in 7 of 28 patients despite no significant diameter reduction of identified coronary segments.(ABSTRACT TRUNCATED AT 250 WORDS)