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 American and European 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 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.
The ESC guidelines2 2019 were updated accordingly to include an increased focus on microvascular dysfunction.
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.
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.
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:
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
Indications: CoroFlow‡ is indicated to provide hemodynamic information for use in the diagnosis of patients with cardiovascular diseases.
CoroFlow‡ is intended for use in catheterization and related cardiovascular specialty laboratories to compute and display various physiological parameters based on the output from one or more measuring devices.
Contraindications: The system has no patient alarm functions. Do not use for cardiac/vital signs monitoring.
Indications: The PressureWire™ X Guidewire is indicated to direct a catheter through a blood vessel and to measure physiological parameters in the heart and in the coronary and peripheral blood vessels. Physiological parameters include blood pressure. The PressureWire™ X Guidewire can also measure blood temperature.
Contraindications: This guidewire is contraindicated for use in the cerebral vasculature.
Potential Adverse Events: Potential complications which may be encountered during all catheterization procedures include, but are not limited to: vessel dissection or occlusion, perforation, embolus, spasm, local and/or systemic infection, pneumothorax, congestive heart failure, myocardial infarction, hypotension, chest pain, renal insufficiency, serious arrhythmias, or death.
In addition, this device has a coating containing Polyethylene Glycol (PEG); potential allergic reactions (anaphylaxis) may occur during the interventional procedure if the patient is allergic to PEG.