Gender-Related Differences in Clinical Presentation and Angiographic Findings in Patients with Ischemia and No Obstructive Coronary Artery Disease (INOCA): A Single-Center Observational Registry

Abstract

Ischemia and no obstructive coronary arteries (INOCA) is a common clinical presentation, with a variety of causes that are often not fully investigated in routine clinical practice. The goal of our study was to characterize a real-world population of patients with INOCA, with a deeper focus on symptoms and stress test findings. The study population consisted of 435 patients who underwent diagnostic coronary angiography for anginal symptoms and/or evidence of myocardial ischemia at non-invasive imaging. In all patients angiography demonstrated nonobstructive coronary artery disease (CAD, less than 30% luminal diameter stenosis or fractional flow reserve > 0.8 and/or instantaneous wave-free ratio > 0.89). Fifty-four percent of the patients were women. Atypical clinical presentation was more common in women (59.5 vs. 49.5%, p = 0.037). Women were more likely to have normal coronary arteries than men (41.8 vs. 16.2%, p < 0.001), and less likely than men to have hemodynamically non-significant CAD (32.1 vs. 55.1%, p < 0.001). No significant correlation between typicality of symptoms and evidence of ischemia was found in those patients (244/435, 56.1%) who had either dobutamine stress echocardiography or electrocardiogram stress test. INOCA is a common clinical condition, prevalent in women often presenting with atypical symptoms.

Symptom Presentation among Women with Suspected Ischemia and No Obstructive Coronary Artery Disease (INOCA)

“…Unlike our significant findings for increased frequency of chest pressure, shortness of breath, and fatigue/weakness/faintness among women with INOCA (all having p < 0.001), as well as a higher frequency trend for symptom aggravation by very hot/cold weather among women with obstructive CAD ( p = 0.025); women of the KoROSE study had no differences between groups for pressure ( p = 0.513), dyspnea ( p = 0.259), syncope ( p = 0.552), and aggravation by low temperature ( p = 0.225) [ 24 ]. Dyspnea was significantly associated with INOCA among both men and women ( p < 0.001) in the CIAO-ISCHEMIA study [ 25 ], and UK investigators [ 26 ] reported a statistical trend for shortness of breath among females with INOCA (12%); however, their comparison group was men with INOCA (6.6%; p = 0.046), using a <70% cutoff [ 26 ]. Our finding of significantly increased fatigue/weakness/faintness among women with INOCA is echoed similarly in a secondary analysis of vital exhaustion among 3656 women with INOCA from the Danish prospective multicenter iPOWER study [ 27 ].…”

MINOCA and INOCA: Role in Heart Failure

“…Women have at least the double expected prevalence of ischaemia from INOCA as confirmed from coronary angiography in comparison to men . In a study of INOCA including patients with stable angina, 70.2% of female versus 43.1% of male patients had coronary microvascular dysfunction (CMD) or epicardial artery vasospasm [ 41 , 42 ] .…”

Current Overview of Diagnostic and Treatment Strategies for Ischemia with Non-obstructive Coronary Artery Disease

“…It is characterized by a range of symptoms, including chest pain, palpitation, and breathlessness [1][2][3] . However, half of patients do not have significant organic stenosis (≥ 50%) of epicardial coronary arteries who undergo coronary angiography (CAG) for clinical symptoms likely to angina or possible myocardial ischemia [4][5][6] .…”

“…It is characterized by a range of symptoms, including chest pain, palpitation, and breathlessness [1][2][3] . However, half of patients do not have significant organic stenosis (≥ 50%) of epicardial coronary arteries who undergo coronary angiography (CAG) for clinical symptoms likely to angina or possible myocardial ischemia [4][5][6] .In 2017, Bairey et al coined the term ischemia with nonobstructive coronary artery disease (INOCA) 7) , and INOCA has since received increased clinical attention worldwide. In 2020, the European Association of Percutaneous Cardiovascular Intervention (EAPCI) proposed the first expert consensus regarding INOCA, which recommended a universal defi nition 8) .…”