Adverse Cardiovascular Outcomes in Women With Nonobstructive Coronary Artery Disease

Abstract

Background Women with clinical findings suggestive of ischemia but without findings of obstructive coronary artery disease (CAD) on angiography represent a frequent clinical problem; predicting prognosis is challenging. Methods The Women’s Ischemia Syndrome Evaluation (WISE) study examined symptomatic women referred for clinically indicated coronary angiography and followed up for a mean 5.2 years. The St James Women Take Heart (WTH) Project enrolled asymptomatic, community-based women with no history of heart disease who were followed up for 10 years. We compared cardiovascular events (ie, myocardial infarction, stroke, and hospitalization for heart failure) and death in 540 WISE women with suspected ischemia but no angiographic evidence of obstructive CAD with those from a cohort of 1000 age- and race-matched WTH women. Results Compared with the WISE women, asymptomatic WTH women had a lower prevalence of obesity, family history of CAD, hypertension, and diabetes mellitus (P<.001). Five-year annualized event rates for cardiovascular events were 16.0% in WISE women with nonobstructive CAD (stenosis in any coronary artery of 1%–49%), 7.9% in WISE women with normal coronary arteries (stenosis of 0% in all coronary arteries), and 2.4% in asymptomatic WTH women (P≤.002), after adjusting for baseline CAD risk factors. The cardiovascular events were most frequent in women with 4 or more cardiac risk factors, with the 5-year annualized cardiovascular event rate being 25.3% in women with nonobstructive CAD, 13.9% in WISE women with normal coronary arteries, and 6.5% in asymptomatic women (P=.003). Conclusion Women with symptoms and signs suggestive of ischemia but without obstructive CAD are at elevated risk for cardiovascular events compared with asymptomatic community-based women.

Variations in Use of Optimal Medical Therapy in Patients With Nonobstructive Coronary Artery Disease: A Population‐Based Study

“…This may explain why, in many patients, there was actually a decrease in the use of these medication classes over 1 year after angiography. This is despite the available evidence suggesting that individuals with nonobstructive CAD have an increased risk for adverse clinical outcomes compared with patients with normal coronary arteries 4, 7, 8. Moreover, there is evidence that medical therapy (in particular, aspirin and statins) improves clinical outcomes in patients with nonobstructive CAD 17, 18.…”

“…Patients with nonobstructive CAD are at increased risk of major adverse cardiovascular events, compared with those with no CAD 4, 7, 8. However, there is less guidance on the best treatment for patients with nonobstructive CAD.…”

Ischemia and No Obstructive Coronary Artery Disease (INOCA): What Is the Risk?

“…Documented MACE rates in stable INOCA patients are summarized in Table 1 4, 10, 15, 26, 35, 36, 37, 38, 39, 40, 41. Additionally, many of these patients have an adverse quality of life, functional status, and exercise capacity with relatively frequent visits to healthcare providers for persistent or recurring disabling symptoms 42.…”

“…In a study of 13 695 subjects, women with nonobstructive CAD demonstrated a 3‐fold higher MACE rate compared with men and 2.55‐fold increase compared with women with normal coronary arteries in the first year 43. Hospitalization for heart failure was the most frequent event, with an observed 10‐fold higher rate during longer‐term follow‐up compared with asymptomatic community‐based women 35. Studies that additionally characterized function or anatomy such as myocardial ischemia, CFR, plaque characterization, or calcium scoring further demonstrate relatively higher MACE rates related to the presence or degree of such abnormalities (Table 1), in both sexes.…”

Local Production of Soluble Urokinase Plasminogen Activator Receptor and Plasminogen Activator Inhibitor‐1 in the Coronary Circulation Is Associated With Coronary Endothelial Dysfunction in Humans

“…Coronary microvascular dysfunction9, 36, 37 and elevated levels of systemic suPAR15, 16, 38 have both been associated with increased major adverse coronary outcomes. Elevated levels of suPAR have also been observed in advanced atherosclerotic disease in both the carotid39, 40 and renal arteries,41 which in turn has been associated with major adverse coronary outcomes.…”