Ischaemia with no obstructive coronary arteries

Abstract

Ischaemia with no obstructive coronary arteries (INOCA) is a common ischaemic heart disease with a female preponderance, mostly due to underlying coronary vascular dysfunction comprising coronary microvascular dysfunction and/or epicardial coronary vasospasm. Since standard ischaemia detection tests and coronary angiograms are not suitable to diagnose coronary vascular dysfunction, INOCA is often overlooked in current cardiology practice. Future research, including large outcome trials, is much awaited. Yet, adequate diagnosis is possible and treatment options are available and vital to reduce symptoms and most probably improve cardiovascular prognosis. This review intends to give a brief overview of the clinical presentation, underlying pathophysiology, and the diagnostic and treatment options in patients with suspected INOCA.

Coronary vasospasm: A narrative review

“…An increased incidence is additionally seen in women, with up to 70% of women showing ACS symptoms without CAD demonstrating findings suggestive of CAVS[ 17 - 19 ]. The incidence is particularly high for younger women under the age of 50 years, as well as non-white women[ 20 , 21 ].…”

“…Current gold standard diagnosis of CAVS utilizes pharmacological provocative testing with high-dose boluses of acetylcholine, ergonovine, or methylergonovine via intracoronary injection[ 2 , 3 , 5 , 13 , 14 ]. The response is then visualized as a coronary vasospasm with transient > 90% occlusion of coronary arteries[ 19 ], during coronary angiography, or via abnormalities of ventricular wall motion on echocardiogram[ 2 , 3 ]. A standard cardiac workup should initially include standard 12-lead electrocardiogram (ECG) during an attack, ambulatory cardiac monitoring, or exercise stress testing to exclude underlying CAD[ 18 ].…”

“…Additionally, sublingual nitrates may be useful for relieving acute episodes of angina[ 5 ]. Statins and angiotensin converting enzyme (ACE) inhibitors have shown efficacy in preventing CAVS episodes, and should be considered in all patients presenting with CAVS[ 2 , 5 , 19 ]. One study analyzed the use of sarpogrelate (a serotonin receptor antagonist) in addition to high-dose statins for CAVS, but did not find significant improvement of outcomes[ 34 ].…”

“…Patients with refractory disease who do not respond to lifestyle changes and first line pharmacotherapy may consider alpha 1-adrenergic receptor antagonists, rho-kinase inhibitors, or nicorandil[ 2 , 5 , 19 ]. Patients with significant atherosclerosis may benefit from percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), which has shown benefit in patients with concomitant CAVS[ 5 ].…”

Coronary Angiography: Indications, Results and Cost-Effectiveness in the Diagnosis of Stable Angina Pectoris in Two Hospitals in Senegal

“…However in the diagnostic approach to myocardial ischemia in stable angina pectoris, several registries or studies have shown that invasive angiographic procedure of some patients with abnormal noninvasive testing does not always reveal the presence of significant lesions on coronary angiography and it's sometimes susceptible to complications [2] [3] [4] [5].…”