Comprehensive treatment of microvascular angina in overweight women – a randomized controlled pilot trial

Abstract

Aims Coronary microvascular dysfunction (CMD) carries a poor cardiovascular prognosis and may explain angina in women without obstructive coronary artery disease (CAD). Currently, no evidence-based treatment for CMD exists. We investigated whether reducing cardiovascular risk factors improves symptoms and microvascular function in women with non-endothelial dependent CMD and no obstructive CAD. Methods We randomized 62 women aged 40–75, with body mass index (BMI) >25 kg/m2, angina ≥monthly, and coronary flow velocity reserve (CFVR) ≤2.5 to a 24-week intervention comprising low energy diet, exercise training, and optimized treatment of hypertension, dyslipidemia and diabetes or to control. Patients were assessed before randomization and after 24 weeks. Primary outcomes were CFVR assessed by transthoracic Doppler stress-echocardiography and angina burden by Seattle Angina Questionnaire (SAQ). Secondary outcomes were exercise capacity, body composition, glycemic control, myocardial function, and anxiety and depression symptoms. Results Fifty-six participants (90%) completed the study. Median (IQR) age was 65.2 (57.1;70.7) years, BMI was 30.1 (28.4;32.7) kg/m2. The intervention resulted in relevant improvement in angina symptoms (9-21-point increase on SAQ-scales (all p<0.01)) but had no effect on CFVR (p = 0.468). Mean (CI) weight loss was 9.6 (7.80;11.48) kg, (p<0.0001). There was a significant mean (CI) decrease in depression symptoms = 1.16 (0.22;2.12), triglycerides = 0.52 (0.25;0.78) mmol/L, total cholesterol = 0.55 (0.12;0.98) mmol/L, and HbA1c in diabetics = 27.1 (1.60;52.6) mmol/mol but no effect on other secondary outcomes. Conclusion A major weight loss and intensified risk factor control resulted in significantly improved angina burden but no improvement of coronary microvascular function among women with microvascular angina.

Ischemia with Nonobstructive Coronary Artery Disease and Atrial Cardiomyopathy—Two Sides of the Same Story?

“…Similarly, it appears that weight loss and improved exercise capacity ameliorate CMD, reflected in increases in CFR assessed by Doppler echocardiography of the left anterior descendent artery [ 94 , 95 ]. Conversely, another trial showed that major weight loss resulted in significantly improved angina symptoms among women with microvascular angina but without amelioration of coronary microvascular function [ 96 ]. Further studies are needed to systematically determine the impact of weight loss on CMD.…”

Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition)

“…To date, a number of small randomized clinical trials or nonrandomized observational studies have reported cardiovascular outcomes in patients with CMVD 140,141 . Large‐sample randomized clinical trials with cardiovascular events as endpoints are underway.…”

“…Lifestyle management in patients with CMVD is similar to that in those with atherosclerosis and includes healthy diet, smoking cessation, and weight control 141,159 . Individualized exercise programs and cardiac rehabilitation can improve angina symptoms, exercise tolerance, quality of life, and CFR in patients with CMVD 160–162 .…”

Management of ischaemia with non-obstructive coronary arteries (INOCA)

“…These anti-ischaemic agents achieve their therapeutic effects via different targets (table 2) and hence are often used in combination. In addition to these conventional agents, novel anti-ischaemic agents have been shown to reduce ischaemia or angina in patients with INOCA including phosphodiesterase-357 and phosphodiesterase-576 inhibitors, rho kinase inhibitors,9697 angiotensin converting enzyme inhibitors72 and estradiol,54 as well as lifestyle risk factor modification8791 (tables 3 and 4).…”