The European Association of Percutaneous Cardiovascular Interventions (EAPCI) Expert Consensus Document defines ischemia and no obstructive coronary artery disease (INOCA) and guidance to its diagnosis and management. The document states that, INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac, leading to under-diagnosis/investigation and under-treatment.1
Both European and American guidelines provide a class IIa recommendation for a physiology wire-based assessment for patients with stable chest pain and/or Ischemia and No Obstructive Coronary Artery Disease (INOCA).2,3
The ESC guidelines2 2019 were updated accordingly to include an increased focus on microvascular dysfunction.
The AHA/ACC Clinical Practice Guideline3 on chest pain includes Class IIa recommendation for guidewire-based assessment for ischemia and no obstructed coronary artery disease (INOCA) patients.
CFR = coronary flow reserve; CMR = cardiac magnetic resonance; ECG = electrocardiogram;
FFR = fractional flow reserve; iwFR = instantaneous wave-free ratio; LAD = left anterior descending; PET = position emission tomography.
a Class of recommendation
b Level of evidence
Level-NR: Level (Quality) of Evidence Level B-NR (non-randomized): moderate-quality evidence from 1 or more well-designed, well-executed non-randomized studies, observational studies or registry studies. RCTs. Meta-analyses of such studies.
Aladie Chieffo MD, Milan, Italy
Symptoms of myocardial ischaemiaa
Absence of obstructive CAD (<50% diameter reduction or FFR >0.80)
Objective evidence of myocardial ischaemiab
Evidence of impaired coronary microvascular function
Kunadian et al. European Heart Journal. 2020; 0:1-21.
Definitive microvascular angina is only diagnosed if criterias 1, 2, 3 and 4 are present.
CAD = coronary artery disease; CCTA = coronary computed tomographic angiography; CFR = coronary flow reserve; ECG = electrocardiogram; FFR = fractional flow reserve; IMR = index of microcirculatory resistance.
a Many patients with heart failure with preserved ejection fraction would fulfil these criteria: dyspnoea, no obstructive CAD and impaired CFR. For this reason, consider measuring LV end-diastolic pressure (normal ≤10 mmHg) and NT-proBNP normal <125 pg/mL.
b Signs of ischaemia may be present but are not necessary. However, evidence of impaired coronary microvascular function should be present.
Allen Jeremias, MD, New York, USA
Colin Berry MD, PhD, Glasgow, UK
Microvascular angina and vasospastic angina are the two most common causes of INOCA, and both types of angina can be identified with diagnostic testing. The randomized CorMicA trial provides a diagnostic and treatment approach.5
The trial protocol assessed patients to determine:
Colin Berry MD, PhD, Glasgow, UK
The CorMicA results indicate a role for a more thorough investigation of coronary microvascular dysfunction among patients with INOCA, as well as an opportunity to better tailor patient treatment.5
The EAPCI Expert Consensus Document1 defines INOCA and provides guidance to the clinical community on the diagnostic approach and management of INOCA based on existing evidence and best current practices.
Angiotensin-converting enzyme inhibitor = ACEI
Angiotensin receptor blocker = ARB
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