An Intravascular Ultrasound Analysis in Women Experiencing Chest Pain in the Absence of Obstructive Coronary Artery Disease: A Substudy from the National Heart, Lung and Blood Institute–Sponsored Women's Ischemia Syndrome Evaluation (WISE)

Abstract

Aims-Using intravascular ultrasound (IVUS), we sought to characterize coronary morphology in women with chest pain without major epicardial obstructive coronary artery disease (CAD). We have previously observed an unexpectedly high rate of adverse outcomes among women with chest pain and normal or insignificant obstructive CAD. Information about the presence and characteristics of coronary atherosclerosis in these women could provide insight into the mechanisms related to increased risk, as well as improved diagnosis, prevention, and treatment.Methods-Women (n=100) with suspected ischemia without obstructive CAD (>50% stenosis) underwent IVUS of a left coronary segment with measurements by a core lab masked to clinical and angiographic findings.Results-Angiograhic core lab analysis found 69.6% of patients had no (≤20%) and 30.4% had minimal (20-<50%) CAD. IVUS segmental images were interpretable by the core lab in 92 women, with 19 (21%) having no atherosclerosis (intimal-medial thickness <0.5 mm). In the remaining 73 women (79%), percent atheroma volume was 27±8% and mean maximum plaque thickness was 0.53±0.22 mm. Thirty-eight women with atherosclerosis (53%) had >30% of interrogated vessel involved. The average vessel involvement was 40%, and the maximum plaque thickness was 1.27 mm. The number of risk factors strongly correlated with percent atheroma volume (r=0.53, p<0.0001) and percent vessel involvement (r=0.51, p<0.0001), with the strongest Address for reprints: R. David

Ischemia and No Obstructive Coronary Artery Disease (INOCA): What Is the Risk?

“…Previously, the term CSX was used to refer to patients with no obstructive CAD but did not require proof of ischemia23, 24 and also included patients with acute coronary syndromes and no obstructive CAD 22, 23, 25. Advanced evaluation can now identify CMD or macrovascular dysfunction by invasive or noninvasive measurements of CFR in a majority of these patients,12, 26 while coronary atherosclerosis and better characterization of plaques can be assessed by intravascular ultrasound, optical coherence tomography, or computed coronary tomography angiography when not evident or appreciated at invasive coronary angiography 27, 28, 29. Since CSX also includes clinical entities other than ischemia, such as pericardial pain, inappropriate pain perception, and psychiatric syndromes,30 the term INOCA was established to improve the identification and management of patients with ischemia and no obstructive CAD 1.…”

2013 Esc Guidelines on the Management of Stable Coronary Artery Disease

“…раздел 6.7.1. по микрососудистой стенокардии) [498]. Тем не менее, замечание о том, что у этих женщин име-ются "нормальные" коронарные артерии, должно быть пересмотрено в свете дополнительного исследо-вания с ВСУЗИ у женщин в рамках исследования WISE (Women's Ischemia Syndrome Evaluation), кото-рое показало, что в выборке из 100 таких женщин приблизительно у 80% имелся определенный коро-нарный атеросклероз, который сопровождался поло-жительным ремоделированием артерий [499]. Пока не получено достаточно доказательств, основанных на исследованиях, женщины с болью в грудной клетке и без обструкции коронарных артерий должны про-ходить скрининг с выявлением факторов риска ССЗ и получать лечение в зависимости от категории риска, как описывается в Рекомендациях по профилактике ССЗ [37], с дополнительным индивидуализирован-ным симптоматическим лечением стенокардии (см.…”

Angina pectoris in patients without flow-limiting coronary artery disease (cardiac syndrome X). A forest of a variety of trees

“…Interestingly, reference segment disease was not an independent predictor of subsequent angiographic restenosis or clinical events within 12 months of follow-up. In the WISE study, 100 consecutive women with normal coronary arteries were studied by intravascular ultrasound and about 80% had atherosclerotic plaques [12]. Extrapolating these findings, most of 48% women in WISE studied who were classified as having normal coronary arteries, would probably have some coronary plaques [13].…”

“…Intravascular ultrasound allows high quality cross-sectional imaging of the coronary arteries in vivo [11,12] and was used to study angiographically normal coronary reference segments in 884 patients evaluated for transcatheter therapy for symptomatic native epicardial coronary artery pathology: only 60 (6.8%) of these angiographically normal reference segments were normal [12]. Reference segments contained less calcific and dense fibrotic plaque and proportionately more soft plaque elements.…”

“…Etiological heterogeneity and prominent contribution of co-morbidities make understanding the pathophysiology of CSX particularly challenging [6,7,[9][10][11][12][13][14][15][16]. It has been, however, established that the interplay of multifactorial mechanisms (Table 1) may cause myocardial ischemia and AP in patients without flow-limiting coronary stenosis, i.e.…”