Temporal Trends of the Prevalence of Angina With No Obstructive Coronary Artery Disease (ANOCA)

Emergency department visits and hospitalizations after a diagnosis of angina with no obstructive coronary artery disease (ANOCA)

BACKGROUND

Angina with no obstructive coronary artery disease (ANOCA) presents diagnostic and treatment challenges, significantly burdening healthcare resources. This study assessed emergency department (ED) visits and hospitalizations and factors associated with these outcomes following ANOCA and stable angina (SA) with obstructive coronary artery disease (CAD) diagnoses.

METHODS

A retrospective cohort of individuals who had their first invasive cardiac catheterization for chest pain in Alberta from 2002 to 2017 was extracted retrospectively from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. Incidence rates (IRs) were calculated for ED visits and hospitalizations, while factors associated with these outcomes were analyzed using Cox models.

RESULTS

Our analysis included 28,881 individuals (ANOCA, 36%). Two-year postcatheterization IRs of ED visits were 100.3-119.3 per 1,000 person-years for ANOCA and increased over time (unstandardized beta coefficient [b] = 2.19 per biennium [95% CI 0.83-3.55]; P = .008); for SA with obstructive CAD the IRs were 209.3-240.2 per 1,000 person-years and remained stable (b = -1.83 per biennium [95% CI -5.73 to 1.70]; P = .25). IRs of hospitalizations were 12.4-25.8 per 1,000 person-years and stable for ANOCA (b = -0.93 per biennium [95% CI -2.49 to 0.64]; P = .20); for SA with obstructive CAD, they were 106.4-171.4 per 1,000 person-years and decreased over time (b = -9.02 per biennium [95% CI -13.27 to -4.77; P = .002). A previous history of heart failure was most associated with ED visits (HR = 1.74 [95% CI 1.41-2.14]; P < .001) and hospitalizations (HR = 2.40 [95% CI 1.82-3.18]; P < .001) for ANOCA.

CONCLUSIONS

ED visits for ANOCA have risen over time while hospitalizations remain stable, indicating a growing burden despite generally lower rates than SA with obstructive CAD. These findings underscore the need for more effective management strategies to address the significant morbidity and resource utilization in ANOCA.

Assessing Coronary Microvascular Dysfunction Using Angiographic Frame Count in Patients With Angina and Nonobstructive Coronary Arteries

BACKGROUND

Coronary microvascular dysfunction (CMD) is underdiagnosed, mainly because of the low clinical adoption of wire-based invasive coronary function testing. Angiography-based, wireless methods might facilitate widespread assessment of CMD. To our knowledge, the diagnostic utility of angiographic Thrombolysis In Myocardial Infarction (TIMI) frame count and frame count reserve (FCR) in identifying CMD in patients with angina and nonobstructive coronary arteries (ANOCA) has never been explored.

METHODS

A total of 140 ANOCA patients underwent coronary angiography and invasive coronary function testing with thermodilution-derived index of microcirculatory resistance (IMR) and coronary flow reserve (CFR). CMD was defined as CFR < 2.5 or IMR ≥ 25. TIMI frame count was measured from resting (TFCrest) and hyperemic (TFChyp) angiography, with FCR calculated as TFCrest/TFChyp.

RESULTS

Among the 140 patients enrolled, the mean age was 63.3 years and 50.7% were women. TFChyp correlated more strongly with IMR than TFCrest (r = 0.557 [P < 0.001] and r = 0.394 [P < 0.001], respectively) and had superior diagnostic performance for CMD with abnormal IMR (area under the curve, 0.810 vs 0.711; P = 0.015). FCR showed a good correlation with CFR (r = 0.686; P < 0.001) and high diagnostic accuracy (area under the curve, 0.871; P < 0.001) for CMD with abnormal CFR. TFChyp ≥ 19 independently predicted CMD with abnormal IMR (odds ratio, 13.11; 95% confidence interval, 5.39-35.59), whereas FCR < 2 independently predicted CMD with abnormal CFR (odds ratio, 24.21; 95% confidence interval, 9.93-65.97).

CONCLUSIONS

TFChyp combined with FCR offers a comprehensive, accurate, wireless alternative for CMD diagnosis, facilitating a broader assessment of CMD in ANOCA patients.

Effects of radial artery spasm prophylaxis on intracoronary vasomotor responses during acetylcholine spasm provocation testing

BACKGROUND

Invasive coronary angiography via the radial approach is commonly performed following radial artery spasm prophylaxis (RASP). It is however unknown, whether RASP influences the results of coronary spasm provocation testing performed after diagnostic angiography. We aimed to investigate the effects of RASP on vasomotor responses during intracoronary acetylcholine (ACh) testing.

METHODS

We retrospectively screened 372 consecutive patients (51 % female, mean age 61 ± 11 years) with angina and non-obstructive coronary arteries, who underwent intracoronary provocation with ACh according to a standardized protocol. During testing, dose-dependent clinical discomfort and concomitant ischemic electrocardiographic changes were recorded in addition to visual reductions of epicardial lumen diameters. Of these patients, 156 (42 %) received RASP (i.e. 200 μg nitroglycerin and 2.5 mg verapamil), while no RASP was administered in 216 (58 %) patients. Both groups were compared regarding age, sex, cardiovascular risk factors and ACh-test results.

RESULTS

ACh provocation testing revealed a pathological test result in 71 patients (46 %) with RASP and 103 patients (48 %) without (p = 0.752) [epicardial spasm: in 20 patients (28 %) with RASP and 42 patients (41 %) without (p = 0.120); microvascular spasm: in 51 patients (72 %) with RASP and 61 patients (59 %) without (p = 0.362)]. Overall, RASP did not significantly alter coronary artery vasomotor responses, neither regarding the frequency (p = 0.752) or type of coronary spasm (microvascular vs. epicardial; p = 0.108) nor regarding the ACh dose leading to spasm (p = 0.151).

CONCLUSIONS

RASP does not significantly affect coronary vasomotor responses to ACh, suggesting that radial artery spasm prophylaxis can be routinely administered even in patients in whom intracoronary spasm testing is performed.

Characterizing chest pain in patients with acute coronary syndrome at Vietnam National Heart Institute: a case-control study

OBJECTIVE

This study aimed to distinguish chest pain characteristics between patients with and without acute coronary syndrome (ACS) at Vietnam National Heart Institute.

METHODS

A case-control study using a structured chest pain assessment questionnaire was performed to examine pain characteristics.

RESULTS

Smoking, a history of heart attack, and a family history of cardiovascular disease were associated with increased ACS-related chest pain risk. Patients without ACS more frequently reported left or central chest pain, mild discomfort, pain triggered by activity, and relief with rest or nitroglycerin. ACS-related chest pain was more often characterized by pain radiating to the back, a sensation of tightness or severe discomfort, gradual intensity increase, occurrence at rest or with minimal exertion, and accompanying sweating. No significant sex differences were found in ACS-related chest pain symptoms.

CONCLUSIONS

Targeted assessment of chest pain features-such as pain radiation, pressure sensation, symptom escalation, duration, activity triggers, and relief factors-could improve public awareness and support the development of educational resources on ACS and non-ACS symptoms.

[Diagnosis and treatment of patients with ANOCA. Consensus document of the SEC-Clinical Cardiology Association/SEC-Interventional Cardiology Association/SEC-Ischemic Heart Disease and Acute Cardiac Care Association/ SEC-Cardiovascular Imaging Association]

A substantial number of patients undergoing coronary angiography for angina or ischemia in noninvasive tests have coronary arteries without lesions or with nonsignificant stenosis. Many of these patients have nonobstructive myocardial ischemia (INOCA/ANOCA), which is an entity with prognostic importance that significantly affects patients' quality of life. The absence of a proper diagnosis leads to inappropriate medical treatment, repeat diagnostic tests, and greater use of social and health resources. An adequate diagnostic strategy is required for individualized treatment that improves symptoms and quality of life. In this document from the SEC-Clinical Cardiology Association, SEC-Interventional Cardiology Association, SEC-Ischemic Heart Disease and Acute Cardiac Care Association, and SEC-Cardiovascular Imaging Association of the Spanish Society of Cardiology, we provide simple and practical algorithms, with the aim of facilitating the early diagnosis and most appropriate treatment for patients with ANOCA.

Chemokine Fractalkine and Non-Obstructive Coronary Artery Disease-Is There a Link?

Non-obstructive coronary artery disease (NO-CAD) constitutes a heterogeneous group of conditions collectively characterized by less than 50% narrowing in at least one major coronary artery with a fractional flow reserve (FFR) of ≤0.80 observed in coronary angiography. The pathogenesis and progression of NO-CAD are still not fully understood, however, inflammatory processes, particularly atherosclerosis and microvascular dysfunction are known to play a major role in it. Chemokine fractalkine (FKN/CX3CL1) is inherently linked to these processes. FKN/CX3CL1 functions predominantly as a chemoattractant for immune cells, facilitating their transmigration through the vessel wall and inhibiting their apoptosis. Its concentrations correlate positively with major cardiovascular risk factors. Moreover, promising preliminary results have shown that FKN/CX3CL1 receptor inhibitor (KAND567) administered in the population of patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), inhibits the adverse reaction of the immune system that causes hyperinflammation. Whereas the link between FKN/CX3CL1 and NO-CAD appears evident, further studies are necessary to unveil this complex relationship. In this review, we critically overview the current data on FKN/CX3CL1 in the context of NO-CAD and present the novel clinical implications of the unique structure and function of FKN/CX3CL1 as a compound which distinctively contributes to the pathomechanism of this condition.

Coronary Vascular (DYS) Function and Invasive Physiology Assessment: Insights into Bolus and Continuous Thermodilution Methods

A considerable number of patients with angina or myocardial ischemia have no significant coronary artery disease on invasive angiography. In recent years, several steps towards a better comprehension of the pathophysiology of these conditions, angina or ischemia with non-obstructive coronary arteries (ANOCA/INOCA), have been made. Nevertheless, several gaps in knowledge still remain. This review is intended to provide a comprehensive overview of ANOCA and INOCA, with a particular focus on pathophysiology, recent diagnostic innovations, gaps in knowledge and treatment modalities.