Coronary Microvascular Dysfunction

How to diagnose INOCA

The recently published European Association of Percutaneous Cardiovascular Interventions (EAPCI) Expert Consensus Document defines INOCA and guidance to its diagnosis and management.1

ESC guidelines recommend measuring coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) using a guidewire-based approach.2

hemodynamic system’s coronary flow reserve identifies CMD

EAPCI Consensus Document on INOCA
Alaide Chieffo MD, Milan, Italy

microvasculature is not viewed on angiogram

Kunadian et al. European Heart Journal. 2020; 0:1-21.

An updated standardization of CMD criteria is provided by the COVADIS group including the cut-off values of CFR<2.0 and IMR≥25 that characterize CMD.1

Kunadian et al. European Heart Journal. 2020; 0:1-21.

The Microvasculature Can Have a Major Impact: Clinical and Economic Outcomes

The microcirculation carries far more myocardial blood volume compared to the epicardial arteries. CMD can be defined as impaired CFR in the absence of epicardial obstructive CAD—i.e., downstream vasomotor dysfunction.3

INOCA Is Not Benign: The Impact on Clinical Outcomes

Patients with INOCA, including those diagnosed with CMD, have an increase in major adverse cardiac events (MACE) including:

  • Myocardial infarction4
  • Stroke4
  • Diastolic dysfunction3 and heart failure3,4
  • Cardiovascular death4
  • Cardiac death3
  • All-cause mortality4

Coronary Flow Reserve Associated with MACE Risks3

Reduced coronary flow reserve is associated with adverse events

Image adapted from Taqueti et al, J Am Coll Cardiol 20183

The clinical spectrum of CMD may be characterized by three factors:3

  • The severity of CMD
  • The degree of atherosclerosis
  • Any associated clinical risks

Clinical Spectrum of CMD

MACE risk increases with CMD severity

Image adapted from Taqueti et al, J Am Coll Cardiol 20183

The Impact on Healthcare Costs, Cath Labs, and Patients

INOCA frequently impacts patient quality of life (QOL) and consumes significant health care expenditures.5,6 With multiple evaluations and frequent hospitalization5,6, each additional hospitalization can add $2,100 (the Netherlands) to $7,300 (the U.S.) in healthcare costs.7

Nevertheless, it is possible to accurately diagnose patients on their first visit to the cath lab and to provide effective treatment.

How to Diagnose CMD with the PressureWire™ X Guidewire

The PressureWire™ X Guidewire and Coroventis CoroFlow Cardiovascular System can measure both IMR and CFR - allowing for a CMD diagnosis.8

How to measure IMR
Allen Jeremias, MD, New York, USA

Diagnosis with Comprehensive Physiology Indices
Colin Berry MD, PhD, Glasgow, UK

Pressure and temperature sensors

only medical guidewire to diagnose CMD: PressureWire™ X
Angina and negative angiogram could mean CMD

Image adapted from Lee et al, J Am Coll Cardiol 20155


Having a comprehensive physiology testing of both the epicardial arteries and microcirculation can provide clear diagnosis to guide treatment and outcomes.5


How to Treat CMD with Pressurewire™ X GUIDEWIRE: Results of the CorMicA Trial

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.9

The trial protocol assessed patients to determine:

CorMicA Findings
Colin Berry MD, PhD, Glasgow, UK

CorMicA Trial: 1-Year RCT Outcomes9

CorMicA Trial: 1-Year RCT Outcomes
CorMicA Trial: 1-Year RCT Outcomes

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.9

INOCA Patient Management

INOCA is not benign and associated with under-diagnosis, under-treatment and poor prognosis. The EAPCI Expert Consensus Document 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.1

microvasculature is not viewed on angiogram

Kunadian et al. European Heart Journal. 2020; 0:1-21.
angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB)

  • 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. Knuuti J, Wijns W, Saraste A, et al., for the Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC). 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41:407-477. doi:10.1093/eurheartj/ehz425.
    3. 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.
    4. 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.
    5. 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.
    6. Reriani M, Flammer AJ, Duhé J, et al. Coronary endothelial function testing may improve long-term quality of life in subjects with microvascular coronary endothelial dysfunction. Open Heart. 2019;6:e000870. doi: 10.1136/openhrt-2018-000870.
    7. Omerovic E. FFR-Guided Complete Revascularization During Primary Angioplasty: Effects on Societal Costs. EuroPCR 2017.
    8. PressureWire X guidewire IFU. Coroventis CoroFlow Cardiovascular System IFU.
    9. 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.
    10. Ford TJ, Stanley B, Good R, et al. Stratified medical therapy using invasive coronary function testing in angina: the CorMicA trial. J Am Coll Cardiol. 2018;72:2841-2855.

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