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CARDIOVASCULAR
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Angiography Doesn't Tell You the Whole Story

Angioplasty doesn't tell you the whole story

Approximately 112 million people globally are affected by angina and undergo coronary angiography, the primary diagnostic test for angina.1 Unfortunately, angiography is limited to assessing the epicardial arteries and cannot assess the microcirculation, which is largely responsible for the regulation and distribution of blood flow to the myocardium.2 Additionally, too often patients with ischemia with non-obstructive coronary arteries (INOCA) on angiography—remain undiagnosed.3 About 40-60% of chronic coronary syndrome (CCS) patients undergoing angiography have INOCA, and a large proportion of these patients may have coronary microvascular dysfunction (CMD).4,5 Proper diagnosis of CMD and treatment is the only way to improve outcomes in these patients at high risk for major adverse cardiac events (MACE).4

The uncertainty with microvascular disease to the physician and the patient

Javier Escaned MD, PhD, Madrid, Spain

How Patients Benefit from a Microvascular Dysfunction Diagnosis

The recent Coronary Microvascular Angina (CorMicA) trial revealed that patients may benefit when coronary microvascular dysfunction is accurately diagnosed and appropriately treated:6

 

27% improvement in angina severity

IMPROVEMENT IN ANGINA SEVERITY

Sustained Angina Improvement with CMD Treatment6,†

sustained angina improvement with cmd treatment

† According to the Seattle Angina Questionnaire score.

The CorMicA study data6 reveals that adequate evaluation and optimal treatment of patients who have ischemia with non-obstructive coronary arteries (INOCA) can:

  • Relieve patient symptoms
  • Improve patient quality of life (QOL)
  • Reduce healthcare resource consumption

When patients are diagnosed and treated in fewer cath lab visits, overall healthcare costs may be reduced accordingly.

Challenges of Diagnosing Underlying Causes of Chest Pain

 

Ischemic heart disease continues to be the leading cause of death globally.7  Yet chest pain—while often ischemic in nature—could have many etiologies, as illustrated.8 When chest pain is caused by ischemia (angina), proper management depends on accurately identifying and treating the underlying cause of angina.

Chest pain can have many underlying causes

Here are some of the structural and functional causes of recurrent or persistent angina despite non-obstructive coronary artery disease.9

 

 

RECURRENT OR PERSISTENT ANGINA

Structural Causes9
  • In-stent restenosis
  • Stent thrombosis
  • Progression of atherosclerotic disease in other segments
  • Incomplete revascularization
  • Diffuse atherosclerotic disease without focal stenosis
  • Presence of myocardial bridges

Functional Causes9
  • Coronary microvascular dysfunction
  • Epicardial vasospasm
  • Stent-related mechanical stretch of the arterial wall

The common diagnosis of Ischemia with non-obstructive coronary arterIEs (INOCA)

Only 41% of patients assessed for angina are found to have obstructive chronic coronary artery disease.4 The majority (59%) have no angiographic abnormalities,4 but still have symptoms of a coronary disorder.10

Most angiograms yield no coronary artery disease

20-30% of patients experience recurrent angina in 1 year after percutaneous coronary intervention (PCI).11

 

20-30% of patients experience recurrent angina in 1 year after percutaneous coronary intervention (PCI)

INOCA patients with persistent angina frequently remain underdiagnosed. Without a clear diagnosis and treatment, this may result in recurrent hospitalizations, poor functional health, and adverse cardiovascular outcomes.12

Up to 50-65% of patients who have angina but non-obstructive CAD are believed to have coronary microvascular dysfunction (CMD).8

  • References
    1. Kunadian V, Chieffo A, Camici PG, et al. An EAPCI Expert Consensus Document on Ischaemic with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. European Heart Journal. 2020; 0:1-21.
    2. Taqueti VR, Di Carli MF. Coronary microvascular disease pathogenic mechanisms and therapeutic options: JACC state-of-the-art review. J Am Coll Cardiol. 2018;72:2625–2641. doi:10.1016/j.jacc.2018.09.042.
    3. Jespersen L, Hvelplund A, Abildstrøm SZ, et al. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J. 2012;33:734-744. doi:10.1093/eurheartj/ehr331.
    4. Patel MR , Peterson ED , Dai D , et al. Low diagnostic yield of elective coronary angiography. N Engl J Med. 2010;362:886-895. doi:10.1056/NEJMoa0907272.
    5. Maas A, et al. Microvascular angina: diagnosis, assessment, and treatment. EMJ Int Cardiol. 2019; 7[Suppl 1]2-17.
    6. Ford TJ, Stanley B, Sidik N, et al. 1-year outcomes of angina management guided by invasive coronary function testing (CorMicA). J Am Coll Cardiol Intv. 2020;13:33-45.
    7. Wang H, Naghavi M, Allen C, et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1459-544.
    8. Marinescu MA, Löffler AI, Ouellette M, et al. Coronary microvascular dysfunction and microvascular angina: a systematic review of therapies. JACC Cardiovasc Imaging. 2015;8:210-220. doi:10.1016/j.jcmg.2014.12.008.
    9. Niccoli G, Montone RA, Lanza GA, et al. Angina after percutaneous coronary intervention: the need for precision medicine. Int J Cardiol. 2017;248:14-19. doi: 10.1016/j.ijcard.2017.07.105.
    10. Ford TJ, Berry C. How to diagnose and manage angina without obstructive coronary artery disease: lessons from the British Heart Foundation CorMicA Trial. Interv Cardiol Rev. 2019;14(2):76-82.
    11. Jeremias A. Blinded Physiological Assessment of Residual Ischemia after Successful Angiographic PCI. ACC 2019.
    12. Lee B, Lim H, Fearon WF, et al. Invasive evaluation of patients with angina in the absence of obstructive coronary artery disease. Circulation. 2015;131:1054–1060.

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