Assessment of Vascular Dysfunction in Patients Without Obstructive Coronary Artery Disease: Why, How, and When

doi:10.1016/j.jcin.2020.05.052

JACC: Cardiovascular Interventions

Volume 13, Issue 16, 24 August 2020, Pages 1847-1864

https://doi.org/10.1016/j.jcin.2020.05.052 Get rights and content

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open access

Highlights

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Patients with symptoms of INOCA can have treatable coronary vasomotion disorders.
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Epicardial and microvascular vasospasm may cause MI with no obstructive CAD and type 2 MI.
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Invasive physiological testing (functional coronary angiography) helps exclude, diagnose, and treat these conditions.
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Stratified medicine can transform the management and well-being of these patients.

Abstract

Ischemic heart disease secondary to coronary vascular dysfunction causes angina and impairs quality of life and prognosis. About one-half of patients with symptoms and signs of ischemia turn out not to have obstructive coronary artery disease, and coronary vascular dysfunction may be relevant. Adjunctive tests of coronary vasomotion include guidewire-based techniques with adenosine and reactivity testing, typically by intracoronary infusion of acetylcholine. The CorMicA (Coronary Microvascular Angina) trial provided evidence that routine management guided by an interventional diagnostic procedure and stratified therapy improves angina and quality of life in patients with angina but no obstructive coronary artery disease. In this paper, the COVADIS study group provide a comprehensive review of why, how, and when coronary vascular dysfunction should be assessed invasively. They discuss the rationale through a shared understanding of vascular pathophysiology and clinical evidence. They propose a consensus approach to how an interventional diagnostic procedure is performed with focus on practical aspects. Finally, the authors discuss the clinical scenarios in patients with stable and acute coronary syndromes in which measurement of coronary vascular function may be helpful for patient care.

Central Illustration

Key Words

angina

ischemic heart disease

microvascular angina

MINOCA

stratified medicine

vasospastic angina

Abbreviations and Acronyms

CAD

coronary artery disease

CBF

coronary blood flow

CFR

coronary flow reserve

confidence interval

CTCA

computed tomographic coronary angiography

FFR

fractional flow reserve

IDP

interventional diagnostic procedure

IMR

index of microvascular resistance

INOCA

ischemia with no obstructive coronary artery disease

left ventricular

LVEDP

left ventricular end-diastolic pressure

MACE

major adverse cardiovascular event(s)

myocardial bridge

myocardial infarction

MVA

microvascular angina

VSA

vasospastic angina

Cited by (0)

: Dr. Pepine is supported by the National Heart, Lung, and Blood Institute (NHLBI) (R01 HL146158, R01 HL 132448, R01 HL091005, U01 HL064924, U01 HL087366, UM1 HL087366, UM1 HL087366, and UM1 HL087364), the National Institutes of Health (NIH)/National Center for Advancing Translational Sciences (UL1 TR001427), the U.S. Department of Defense (W81XWH1720030 and W81XWH-17-2-0030), NIH/Brigham and Women’s Hospital (5U01 HL130163-02), GE Healthcare (GE-265-303), Merck (MK-1242-001-01), Sanofi (EFC11570), the University of Florida Office of Research (AGR DTD 04-26-2018), CSL Behring (CSL112-3001), BioCardia (BC-14-001-02), Mesoblast (MSB-MPC-CHF001), Ventrix, Athersys, AMI MultiStem, Verily Life Sciences (Project Baseline OSMB), Imbria Pharmaceuticals (Ironwood MSB-MPC-CHF00-DMC), Milestone Pharmaceuticals, Caladrius Biosciences, the Gatorade Trust, and the McJunkin Family Foundation. Dr. Merz has received an unrestricted research grant from Gilead Sciences; has contracts from the NHLBI (N01-HV-68161, N01-HV-68162, N01-HV-68163, and N01-HV-68164); is supported by the National Institute on Aging (U0164829, U01 HL649141, U01 HL649241, K23HL105787, T32HL69751, R01 HL090957, and 1R03AG032631), the National Center for Research Resources (General Clinical Research Center grant MO1-RR00425), the National Center for Advancing Translational Sciences (UL1TR000124), the Edythe L. Broad and Constance Austin Women’s Heart Research Fellowships (Cedars-Sinai Medical Center [CSMC]), the Barbra Streisand Women’s Cardiovascular Research and Education Program (CSMC), the Erika Glazer Women’s Heart Health Project, the California Institute for Precision Medicine and the Adelson Family Foundation (CSMC); has received consulting fees from Medscape (paid to CSMC), Sanofi Vascular (paid to CSMC), NIH and NIH Office of Research on Women’s Health (paid to CSMC), iRhythm, Caladrius (paid to CSMC), and Abbott Diagnostics. Dr. Shimokawa has received support from the Japan Heart Foundation and the Japan Society for Promotion of Science. Dr. Berry is employed by the University of Glasgow, which holds consultancy and/or research agreements with companies that have commercial interests in the diagnosis and treatment of ischemic heart disease, including Abbott Vascular, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, HeartFlow, Menarini Farmaceutica, Opsens, Philips, and Siemens Healthcare; and has received research support from the British Heart Foundation (PG/17/2532884, FS/17/26/32744, and RE/18/6134217) and the Medical Research Council (MR/S005714/1). Dr. Camici is a consultant for Servier; and has received speaker fees from Abbott Vascular. Dr. Ford has acted as a speaker for Abbott Vascular, Boehringer Ingelheim, and Novartis. Dr. Kaski has acted as a speaker for Menarini Farmaceutica and Bayer UK. Drs. Ong and Sechtem have received funding from the Berthold-Leibinger-Foundation; and have received speaking honoraria from Philips/Volcano, Pfizer, and Bayer Healthcare. Dr. Crea has received personal fees from Biotronic, Amgen, AstraZeneca, Servier, Menarini Farmaceutica, and Bristol-Myers Squibb. Dr. Beltrame has received a research grant from AstraZeneca.

: The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Cardiovascular Interventions author instructions page.