Meta-analysis and systematic review of coronary vasospasm in ANOCA patients: Prevalence, clinical features and prognosis

Abstract

BackgroundCoronary artery spasm (CAS), encompassing epicardial and microvascular spasm, is increasingly recognized as cause of angina in patients with non-obstructive coronary artery disease (ANOCA). However, various spasm provocation testing protocols and diagnostic criteria are used, making diagnosis and characterization of these patients difficult and interpretation of study results cumbersome. This review provides a structured overview of the prevalence, characterization and prognosis of CAS worldwide in men and women.MethodsA systematic review identifying studies describing ANOCA patients with CAS was performed. Multiple outcomes (prevalence, clinical features, and prognosis) were assessed. Data, except for prognosis were pooled and analysed using random effects meta-analysis models.ResultsTwenty-five publications (N = 14.554) were included (58.2 years; 44.2% women). Percentages of epicardial constriction to define epicardial spasm ranged from >50% to >90%. Epicardial spasm was prevalent in 43% (range 16–73%), with a higher prevalence in Asian vs. Western World population (52% vs. 33%, p = 0.014). Microvascular spasm was prevalent in 25% (range 7–39%). Men were more likely to have epicardial spasm (61%), women were more likely to have microvascular spasm (64%). Recurrent angina is frequently reported during follow-up ranging from 10 to 53%.ConclusionCAS is highly prevalent in ANOCA patients, where men more often have epicardial spasm, women more often have microvascular spasm. A higher prevalence of epicardial spasm is demonstrated in the Asian population compared to the Western World. The prevalence of CAS is high, emphasizing the use of unambiguous study protocols and diagnostic criteria and highlights the importance of routine evaluation of CAS in men and women with ANOCA.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272100.

Coronary Spasm Testing with Acetylcholine: A Powerful Tool for a Personalized Therapy of Coronary Vasomotor Disorders

“…Consistent with this, Montone et al found a positive response to an ACh test in 58.4% of patients, with a higher prevalence of epicardial compared to microvascular CAS (64.3% vs. 35.7%) [ 7 ], and a large meta-analysis by Mileva et al documented CAS in 62% of 14,427 patients with non-obstructive coronary artery disease (NOCAD) [ 19 ]. In keeping with these findings, the overall incidence was 43% for epicardial CAS and 25% for the microvascular endotype in a meta-analysis by Woudstra et al [ 20 ]. Conversely, in the study by Kornst et al, CVDs were present in 83.8% of patients with ANOCA [ 21 ].…”

“…Differences in invasive provocative test protocols and patient selection might account for the high heterogeneity between studies. Contemporary research supports the hypothesis that the occurrence of CAS is dependent on ACh doses and injection speed [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. Moreover, while a coronary constriction >90% is required to establish epicardial spasm according to the Coronary Vasomotion Disorders International Study (COVADIS) criteria [ 11 ], in some studies, epicardial spasm was diagnosed in case of coronary constriction >50%.…”

Vasospastic angina: a review on diagnostic approach and management

“…Timely recognition of symptoms and suspicion of coronary artery spasm may prevent the occurrence of adverse events such as sudden cardiac death (SCD), MI and syncope. 21 Patients suffering from VSA frequently experience recurrent angina during follow-up, ranging from 10% to 53%, 22 a characteristic in line with the results of the CorMicA (CORonary Microvascular Angina) trial. 23 …”

“… 24 In patients with VSA, more than half of all reported major adverse cardiovascular events (MACE), including cardiac death, nonfatal-MI, unstable angina and hospitalization, is driven by hospitalization for unstable angina ranging from 52% to 90% of MACE. 22 …”

Heart Rate Recovery as a Predictor of Long-Term Adverse Events after Negative Exercise Testing in Patients with Chest Pain and Pre-Test Probability of Coronary Artery Disease from 15% to 65%

“…Firstly, the overall death could be unrelated to CAD. Moreover, angina may be caused by a stenosis of less than 50% with a hemodynamic significance or with a non-obstructive mechanism (i.e., angina with non-obstructive coronary arteries), such as microvascular dysfunction [ 55 , 56 ] or vasospasm [ 57 ]. In addition, it was highlighted that 6–8% of MIs may develop in the presence of non-significant coronary stenosis [ 58 ].…”