Absolute Coronary Blood Flow Measured by Continuous Thermodilution in Patients With Ischemia and Nonobstructive Disease

Self Cite

Introduction: Invasive coronary function testing (CFT) has become the recommended diagnostic tool to assess the various endotypes of coronary vasomotor dysfunction in patients with angina and no obstructive coronary artery disease (ANOCA), which has implications for therapy and prognosis. Although the expanding performance of CFT is leading to increased knowledge of coronary vasomotor dysfunction, little is known about sex-related differences in the results of comprehensive CFT.Methods: We conducted a prospective study of all consecutive patients with ANOCA that underwent clinically indicated CFT in a tertiary interventional from February 2019 to February 2021. CFT consisted of acetylcholine testing to diagnose epicardial or microvascular spasm, and adenosine testing to diagnose CMD. CMD was defined as an index of microvascular resistance (IMR) ≥ 25 and/or coronary flow reserve (CFR) < 2.0.Results: In total, 228 women and 38 men underwent CFT. No differences in traditional risk factors were seen, but women had a higher prevalence of migraine (45 vs. 14%, p = 0.001). Men more often had a history of percutaneous coronary intervention (12 vs. 49%, p = 0.001). We found no difference in clinical presentation. Coronary vasomotor dysfunction was present in 95% of men and 88% of women (p = 0.25), but males show more often epicardial spasm and less microvascular spasm than women (63 vs. 42% and 29 vs. 40% respectively, p = 0.039). Impaired CFR was more prevalent among females (6 vs 20%, p = 0.033). IMR [median of 23 (15–32) vs. 19 (13–25), p = 0.08] did not differ between the sexes.Conclusion: Men undergoing CFT show a comparable prevalence of coronary vascular dysfunction as women. However, men have a higher prevalence of epicardial spasm and a lower prevalence of microvascular spasm compared with women. An impaired CFR was more often present in women, with an equally impairment of IMR.

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Sex Differences in Coronary Function Test Results in Patient With Angina and Nonobstructive Disease

Jansen

Elias‐Smale

Oord

et al. 2021

Self Cite

“…This method has less technical disadvantages and does not require the use of adenosine. Studies have shown this method to be feasible and safe ( 107 , 109 ), and Q and R to be related to symptoms ( 110 ). Future research is needed to further explore the diagnostic value of this promising technique and establish clinically meaningful cut-off values ( 111 ).…”

Section: Knowledge Gaps and Future Directions In Outpatient Managementmentioning

confidence: 99%

Outpatient Management of Patients With Angina With No Obstructive Coronary Arteries: How to Come to a Proper Diagnosis and Therapy

Meeder

Hartzema-Meijer

Jansen

et al. 2021

Self Cite

Two-thirds of women and one-third of men who undergo a clinically indicated coronary angiography for stable angina, have no obstructive coronary artery disease (CAD). Coronary vascular dysfunction is a highly prevalent underlying cause of angina in these so called “Angina with No Obstructive Coronary Arteries (ANOCA)” patients, foremost in middle aged women. Coronary vascular dysfunction encompasses various endotypes, namely epicardial and microvascular coronary spasms, impaired vasodilatation, and increased microvascular resistance. ANOCA patients, especially those with underlying coronary vascular dysfunction, have an adverse cardiovascular prognosis, poor physical functioning, and a reduced quality of life. Since standard ischemia detection tests and coronary angiograms are not designed to diagnose coronary vascular dysfunction, this ischemic heart disease is often overlooked and hence undertreated. But adequate diagnosis is vital, so that treatment can be started to reduce symptoms, reduce healthcare costs and improve quality of life and cardiovascular prognosis. The purpose of this review is to give a contemporary overview of ANOCA with focus on coronary vascular dysfunction. We will provide a possible work-up of patients suspected of coronary vascular dysfunction in the outpatient clinical setting, based on the latest scientific insights and international consensus documents. We will discuss the value of ischemia detection testing, and non-invasive and invasive methods to diagnose coronary vascular dysfunction. Furthermore, we will go into pharmacological and non-pharmacological therapeutic options including anti-anginal regimens and lifestyle interventions.

“…A recent work by Konst et al ( 56 ) reported that absolute microvascular resistance, as assessed by continuous thermodilution, was significantly increased in INOCA, thus suggesting that a functional impairment of the coronary microvascular district plays a central role in INOCA pathophysiological mechanisms.…”

Section: Invasive Functional Assessment: Why So Critical?mentioning

confidence: 98%

“…Multiple contributions support the hypothesis that, even in the absence of critical epicardial CAD, microvascular dysfunction implies impairment of blood flow across coronary vessels ( 53 ), which may also reflect an abnormal resting coronary flow velocity, with a subsequent adverse myocardial performance, thus potentially leading to unfavorable prognosis ( 54 , 55 ). Interestingly, in a cohort of patients with ischemia and non-obstructive coronary arteries (INOCA) who underwent invasive physiological assessment, also including FFR, acetylcholine testing, and adenosine administration, absolute coronary flow measured with continuous thermodilution, resulted as the best predictor of self-reported angina ( 56 ).…”

Section: Invasive Functional Assessment: Why So Critical?mentioning

confidence: 99%

The Pivotal Role of Invasive Functional Assessment in Patients With Myocardial Infarction With Non-Obstructive Coronary Arteries (MINOCA)

Mangiacapra

Viscusi

Paolucci

et al. 2021

Myocardial infarction with non-obstructive coronary arteries (MINOCA) encompasses several pathophysiological mechanisms not yet fully understood. Among the latter, vasomotion abnormalities and coronary microvascular dysfunction (CMD) play a major role for both epidemiological and prognostic reasons. Despite current guidelines do not recommend routine physiological assessment of both epicardial and microvascular coronary compartments within the context of an acute myocardial infarction, several recent evidence support the critical role of a comprehensive invasive functional assessment in order to identify the underlying pathophysiological mechanism and consequently to select an appropriate therapeutic strategy. Unfortunately, optimal medical therapy for these patients is not currently established due to the lack of dedicated trials evaluating clinical outcomes of commonly used medications for secondary prevention in MINOCA patients. For this reason, additional research is warranted to provide personalized treatments for patients affected by this puzzling clinical entity.