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Clinical Relevance of Ischemia with Nonobstructive Coronary Arteries According to Coronary Microvascular Dysfunction

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Author(s)
Seung Hun LeeDoosup ShinJoo Myung LeeTim P. van de HoefDavid HongKi Hong ChoiDoyeon HwangCoen K. M. BoerhoutGuus A. de WaardJi‐Hyun JungHernan Mejia‐RenteriaMasahiro HoshinoMauro Echavarria‐PintoMartijn MeuwissenHitoshi MatsuoMaribel Madera‐CamberoAshkan EftekhariMohamed A. EffatTadashi MuraiKoen MarquesJoon‐Hyung DohEvald H. ChristiansenRupak BanerjeeHyun Kuk KimChang‐Wook NamGiampaolo NiccoliMasafumi NakayamaNobuhiro TanakaEun‐Seok ShinSteven A. J. ChamuleauNiels van RoyenPaul KnaapenBon Kwon KooTsunekazu KakutaJavier EscanedJan J. Piek
Keimyung Author(s)
Nam, Chang Wook
Department
Dept. of Internal Medicine (내과학)
Journal Title
J Am Heart Assoc
Issued Date
2022
Volume
11
Issue
9
Keyword
coronary flow reservecoronary microvascular diseaseischemia with nonobstructive coronary arteriesmyocardial ischemiaprognosis
Abstract
Background:
In the absence of obstructive coronary stenoses, abnormality of noninvasive stress tests (NIT) in patients with chronic coronary syndromes may indicate myocardial ischemia of nonobstructive coronary arteries (INOCA). The differential prognosis of INOCA according to the presence of coronary microvascular dysfunction (CMD) and incremental prognostic value of CMD with intracoronary physiologic assessment on top of NIT information remains unknown.

Methods and Results:
From the international multicenter registry of intracoronary physiologic assessment (ILIAS [Inclusive Invasive Physiological Assessment in Angina Syndromes] registry, N=2322), stable patients with NIT and nonobstructive coronary stenoses with fractional flow reserve >0.80 were selected. INOCA was diagnosed when patients showed positive NIT results. CMD was defined as coronary flow reserve ≤2.5. According to the presence of INOCA and CMD, patients were classified into 4 groups: group 1 (no INOCA nor CMD, n=116); group 2 (only CMD, n=90); group 3 (only INOCA, n=41); and group 4 (both INOCA and CMD, n=40). The primary outcome was major adverse cardiovascular events, a composite of all‐cause death, target vessel myocardial infarction, or clinically driven target vessel revascularization at 5 years. Among 287 patients with nonobstructive coronary stenoses (fractional flow reserve=0.91±0.06), 81 patients (38.2%) were diagnosed with INOCA based on positive NIT. By intracoronary physiologic assessment, 130 patients (45.3%) had CMD. Regardless of the presence of INOCA, patients with CMD showed a significantly lower coronary flow reserve and higher hyperemic microvascular resistance compared with patients without CMD (P<0.001 for all). The cumulative incidence of major adverse cardiovascular events at 5 years were 7.4%, 21.3%, 7.7%, and 34.4% in groups 1 to 4. By documenting CMD (groups 2 and 4), intracoronary physiologic assessment identified patients at a significantly higher risk of major adverse cardiovascular events at 5 years compared with group 1 (group 2: adjusted hazard ratio [HRadjusted], 2.88; 95% CI, 1.52–7.19; P=0.024; group 4: HRadjusted, 4.00; 95% CI, 1.41–11.35; P=0.009).

Conclusions:
In stable patients with nonobstructive coronary stenoses, a diagnosis of INOCA based only on abnormal NIT did not identify patients with higher risk of long‐term cardiovascular events. Incorporating intracoronary physiologic assessment to NIT information in patients with nonobstructive disease allowed identification of patient subgroups with up to 4‐fold difference in long‐term cardiovascular events.
Keimyung Author(s)(Kor)
남창욱
Publisher
School of Medicine (의과대학)
Citation
Seung Hun Lee et al. (2022). Clinical Relevance of Ischemia with Nonobstructive Coronary Arteries According to Coronary Microvascular Dysfunction. J Am Heart Assoc, 11(9), e025171. doi: 10.1161/JAHA.121.025171
Type
Article
ISSN
2047-9980
Source
https://www.ahajournals.org/doi/full/10.1161/JAHA.121.025171
DOI
10.1161/JAHA.121.025171
URI
https://kumel.medlib.dsmc.or.kr/handle/2015.oak/44316
Appears in Collections:
1. School of Medicine (의과대학) > Dept. of Internal Medicine (내과학)
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