How to Diagnose and Manage Angina Without Obstructive Coronary Artery Disease: Lessons from the British Heart Foundation CorMicA Trial

Abstract

Patients with symptoms and/or signs of ischaemia but no obstructive coronary artery disease (INOCA) present a diagnostic and therapeutic challenge. Microvascular and/or vasospastic angina are the two most common causes of INOCA; however, invasive coronary angiography lacks the sensitivity to diagnose these functional coronary disorders. In this article, the authors summarise the rationale for invasive testing in the absence of obstructive coronary disease, namely that correct treatment for angina patients starts with the correct diagnosis. They provide insights from the CORonary MICrovascular Angina (CorMicA) study, where an interventional diagnostic procedure was performed with linked medical therapy to improve patient health. Identification of these distinct disorders (microvascular angina, vasospastic angina or non-cardiac chest pain) is key for stratifying INOCA patients, allowing prognostic insights and better patient care with linked therapy based on contemporary guidelines. Finally, they propose a framework to diagnose and manage patients in this common clinical scenario.

Angina: contemporary diagnosis and management

“…The contributors to the physiological myocardial perfusion gradient and resultant ischaemia can be broken down at patient-level into systemic, cardiac and coronary factors. CAD, coronary artery disease; SEVR, subendocardial viability ratio.<Modified with permission from 47>.…”

“…We contend that a complete diagnostic evaluation of the coronary circulation should assess structural and functional pathology 47. The British Heart Foundation CorMicA trial provides evidence about the opportunity to provide a specific diagnosis to patients with angina using an interventional diagnostic procedure (IDP) when obstructive CAD is excluded by invasive coronary angiography.…”

Ischaemia with no obstructive coronary arteries

“…Various entities of ischaemic heart disease. Recommended treatment options for patients with INOCA, based on the results of the CorMicA trial [50] Standard ischaemia detection tests and coronary angiograms are not suitable for diagnosing coronary vascular dysfunction [4,7], but it can be evaluated with an invasive coronary reactivity test (CRT) assessing macrovascular and microvascular coronary artery spasms, coronary flow reserve (CFR) and microvascular resistance [5,6]. However, as this test is done in relatively few cardiovascular centres worldwide, this ischaemic heart disease is often overlooked and hence undertreated, especially in women.…”

Ethiopathogenesis and prognostic implication in myocardial infarction without obstruction of the epicardial coronary arteries (MINOCA)

“…Para aquellos pacientes que tienen evidencia de enfermedad aterosclerótica en la circulación coronaria y no se encuentra una causa probable del evento isquémico, es razonable atribuir el síndrome coronario agudo a la enfermedad aterosclerótica e iniciar tratamiento con anti-agregantes plaquetarios, betabloqueantes y estatinas . Esto nos genera una serie de interrogantes que en muchos casos no llegamos a (15)(16)(17) dilucidar por completo: ¿Es el mismo mecanismo de daño miocárdico que el de los pacientes con obstrucción de las arterias coronarias?, ¿deberían ser manejados con las mismas estrategias terapéuticas?, ¿el pronóstico a largo plazo es el mismo en estos pacientes? Por lo tanto, es nuestra intención analizar esto1s aspectos interesantes de esta entidad nosológica a la luz de los últimos hallazgos de la medicina basada en la evidencia.…”