Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events

Jespersen, Lasse; Hvelplund, Anders; Abildstrøm, Steen Zabell; Pedersen, Frants; Galatius, Søren; Madsen, Jan Kyst; Jørgensen, Erik; Kelbæk, Henning; Prescott, Eva

doi:10.1093/eurheartj/ehr331

Cited by 756 publications

(608 citation statements)

References 27 publications

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“…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.…”

Section: Discussionmentioning

confidence: 99%

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

Oxner

Elbaz‐Greener

Qui

et al. 2017

JAHA

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BackgroundThere is a paucity of data on the need for optimal medical therapy (OMT) in nonobstructive coronary artery disease . We sought to understand if there was variation in the use of OMT between hospitals for patients with nonobstructive coronary artery disease, the factors associated with such variation, and its clinical consequences.Methods and ResultsUsing a population‐level clinical registry in Ontario, Canada, we identified all patients >66 years undergoing coronary angiography for the indication of stable angina, who had nonobstructive coronary artery disease between November 1, 2010, and October 31, 2013. Hierarchical multivariable logistic models were developed to identify the factors associated with OMT use, with median odds ratio used to quantify the degree of variation between hospitals not explained by the modeled risk factors. Clinical outcomes of interest were all‐cause mortality and rehospitalization, with follow‐up until March 31, 2015. Our cohort consisted of 5413 patients, of whom 2554 (47.2%) were receiving OMT within 1 year. There was a 2‐fold variation in OMT across hospitals (30.4%–61.8%). The variation between hospitals was fully explained by preangiography medication use (median odds ratio of 1.21 in the null model and 1.03 in the full model). There was no difference in risk‐adjusted mortality (hazard ratio, 0.94; 95% confidence interval, 0.76–1.16); however, patients receiving OMT had a lower risk of all‐cause hospital readmission (hazard ratio, 0.89; 95% confidence interval, 0.84–0.95).ConclusionsThere is wide variation in the use of OMT in patients with nonobstructive coronary artery disease, the major driver of which is differences in baseline medication use.

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Section: Discussionmentioning

confidence: 99%

“…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.…”

mentioning

confidence: 99%

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

Oxner

Elbaz‐Greener

Qui

et al. 2017

JAHA

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“…Depending on the study, up to half of patients undergoing coronary angiography have no obstructive CAD,13, 14, 15 with a relatively higher prevalence in women (65% in women versus 32% in men) 15. Overall estimates in women and men from the Veterans Administration Cardiovascular Assessment Reporting and Tracking System,16 the National Cardiac Data Registry, and the National Heart, Lung, and Blood Institute–sponsored Women's Ischemia Syndrome Evaluation (WISE)10 databases indicate that there are at least 3 to 4 million American women and men with stable INOCA.…”

Section: Inoca—prevalencementioning

confidence: 99%

“…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.…”

Section: Evidence Of An Adverse Prognosismentioning

confidence: 99%

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

Herscovici

Sedlak

Wei

et al. 2018

JAHA

139

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“…Several studies investigated the prognostic impact of the extent of anatomical nonobstructive disease evaluated by coronary angiography9, 20 or coronary computed tomography angiography 8, 21, 22. In the CONFIRM (coronary CT angiography evaluation for clinical outcomes: an international multicenter registry) registry,22 patients with 2‐ or 3‐vessel involvement of nonobstructive (1–49% diameter stenosis) CAD on coronary computed tomography angiography had a 3‐fold higher risk of all‐cause mortality than normal subjects.…”

Section: Discussionmentioning

confidence: 99%

Clinical Relevance of Functionally Insignificant Moderate Coronary Artery Stenosis Assessed by 3‐Vessel Fractional Flow Reserve Measurement

Park

Lee

Koo

et al. 2018

JAHA

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BackgroundUnderstanding of the risk conferred by functionally insignificant lesions in multiple coronary vessels is limited. We investigated the prognostic implications of coronary artery disease (CAD) based on 3‐vessel fractional flow reserve (FFR).Methods and ResultsA total of 1,136 patients underwent FFR measurement in the 3 major epicardial arteries. We defined vessels with “Moderate CAD” as vessels with FFR, 0.81 to 0.87. Patients were classified into Group 1: No apparent CAD (FFR>0.87 in all 3‐vessels); Group 2: Single‐vessel moderate CAD; Group 3: Multivessel moderate CAD; and Group 4: Functionally significant CAD (FFR≤0.80) in any vessel. The primary end point was 2‐year major adverse cardiac events, a composite of cardiac death, myocardial infarction, and ischemia‐driven revascularization. Forty‐three percent of patients had moderate CAD (Group 2: 403/1136, 35.5%; Group 3: 84/1136, 7.4%). The 2‐year risk of major adverse cardiac events was not significantly different between patients with single‐vessel moderate CAD and no apparent CAD (2.6 versus 2.6%; HR, 1.1; 95% confidence interval, 0.4%–2.8%; P=0.89). However, patients with multivessel moderate CAD were at significantly higher risk than Group 1 (7.4 versus 2.6%; hazard ratio, 3.3; 95% confidence interval, 1.1%–9.8%; P=0.03). The risk of major adverse cardiac events in patients with multivessel moderate CAD was comparable to that of patients with functionally significant CAD (hazard ratio, 1.2; 95% confidence interval, 0.5%–3.0%; P=0.67). In a multivariable regression model, multivessel moderate CAD was an independent predictor of greater risk of 2‐year major adverse cardiac events.ConclusionsGlobal physiologic assessment with FFR measurement of 3 vessels can identify multivessel moderate CAD. The prognostic implication of multivessel moderate CAD appears comparable to that of functionally significant CAD.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01621438.

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Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events

Abstract: Patients with stable angina and normal coronary arteries or diffuse non-obstructive CAD have elevated risks of MACE and all-cause mortality compared with a reference population without ischaemic heart disease.

Cited by 756 publications

References 27 publications

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

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

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

Clinical Relevance of Functionally Insignificant Moderate Coronary Artery Stenosis Assessed by 3‐Vessel Fractional Flow Reserve Measurement

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