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Abstract
Up to half of patients undergoing elective coronary angiography for the investigation of chest pain do not present with evidence of obstructive coronary artery disease. These patients are often discharged with a diagnosis of non-cardiac chest pain, yet many could have an ischaemic basis for their symptoms. This type of ischaemic chest pain in the absence of obstructive coronary artery disease is referred to as INOCA (ischaemia with non-obstructive coronary arteries). This comprehensive review of INOCA management looks at why these patients require treatment, who requires treatment based on diagnostic evaluation, what clinical treatment targets should be considered, how to treat patients using a personalised medicine approach, when to initiate treatment, and where future research is progressing.
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Affiliation(s)
- John F Beltrame
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
| | - Rosanna Tavella
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
| | - Dione Jones
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
| | - Chris Zeitz
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
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Schumann CL, Mathew RC, Dean JHL, Yang Y, Balfour PC, Shaw PW, Robinson AA, Salerno M, Kramer CM, Bourque JM. Functional and Economic Impact of INOCA and Influence of Coronary Microvascular Dysfunction. JACC Cardiovasc Imaging 2021; 14:1369-1379. [PMID: 33865784 DOI: 10.1016/j.jcmg.2021.01.041] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study sought to better characterize the quality of life and economic impact in patients with symptoms of ischemia and no obstructive coronary disease (INOCA) and to identify the influence of coronary microvascular dysfunction (CMD). BACKGROUND Patients with INOCA have a high symptom burden and an increased incidence of major adverse cardiac events. CMD is a frequent cause of INOCA. The morbidity associated with INOCA and CMD has not been well-characterized. METHODS Sixty-six patients with INOCA underwent stress cardiac magnetic resonance with calculation of myocardial perfusion reserve (MPR); MPR 2.0 to 2.4 was considered borderline-reduced (possible CMD) and MPR <2.0 was defined as reduced (definite CMD). Subjects completed quality of life questionnaires to assess the morbidity and economic impact of INOCA. Questionnaire results were compared between INOCA patients with and without CMD. In addition, logistic regression was used to determine the predictors of CMD within the INOCA population. RESULTS The prevalence of definite CMD was 24%. Definite or borderline CMD was present in 59% (MPR ≤2.4). Patients with INOCA reported greater physical limitation, angina frequency, and reduced quality of life compared to referent stable coronary artery disease and acute myocardial infarction populations. In addition, Patients with INOCA reported frequent time missed from work and work limitations, suggesting a substantial economic impact. No difference was observed in reported symptoms between INOCA patients with and without CMD. Glomerular filtration rate and body-mass index were significant predictors of CMD in multivariable regression analysis. CONCLUSIONS INOCA is associated with high morbidity similar to other high-risk cardiac populations, and work limitations reported by Patients with INOCA suggest a substantial economic impact. CMD is a common cause of INOCA but is not associated with increased morbidity. These results suggest that there is significant symptom burden in the INOCA population regardless of etiology.
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Affiliation(s)
- Christopher L Schumann
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Roshin C Mathew
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, Charlottesville, Virginia, USA
| | - John-Henry L Dean
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Yang Yang
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, Charlottesville, Virginia, USA; Biomedical Engineering and Imaging Institute and Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pelbreton C Balfour
- Baptist Heart & Vascular Institute and Cardiology Consultants, Pensacola, Florida, USA
| | - Peter W Shaw
- Berkshire Medical Center, Pittsfield, Massachusetts, USA
| | - Austin A Robinson
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michael Salerno
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, Charlottesville, Virginia, USA; Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA; Department of Biomedical Engineering, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Christopher M Kramer
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, Charlottesville, Virginia, USA; Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jamieson M Bourque
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, Charlottesville, Virginia, USA; Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA.
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Effects of a Cardiac Rehabilitation Program Versus Usual Care on Cardiopulmonary Function in Patients With Cardiac Syndrome X. J Cardiopulm Rehabil Prev 2019; 40:41-47. [PMID: 31869312 DOI: 10.1097/hcr.0000000000000439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Because of uncertainty in the pathophysiological process, the treatment of cardiac syndrome X (CSX) is still under study. Addressing the effects of cardiac rehabilitation (CR) can help promote the prescription of this modality as an adjuvant therapy for these patients. METHODS This study was performed on 30 patients with effort-induced angina pectoris using a positive exercise test and/or myocardial perfusion scan in the absence of obvious stenosis or a stenosis of <50% on coronary angiography. The patients were divided into the CR and usual care (UC) groups and underwent cardiopulmonary exercise testing with gas exchange analysis before and after the study. The Duke Treadmill Score was used to compare prognosis and survival estimates of patients. RESULTS An increase in peak oxygen uptake ((Equation is included in full-text article.)O2) was significantly higher in the CR group than in the control group (P = .017). Resting (Equation is included in full-text article.)O2 was also increased in the CR group, but its difference with the UC group was not statistically significant. Resting O2 pulse was increased in the CR group, which significantly differed between groups (P = .041). Exercise test duration and the Duke Treadmill Score significantly increased in the CR group as compared with the UC group (P = .003 and P = .002, respectively). Also, recovery heart rate in the first minute was significantly improved in CR group. CONCLUSION Adding a 4-wk course of CR to UC for patients with CSX not only increased the Duke Treadmill Score and exercise test duration but also improved the resting O2 pulse, peak (Equation is included in full-text article.)O2, and first-minute recovery heart rate.
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Cardiac Rehabilitation and Exercise Prescription in Symptomatic Patients with Non-Obstructive Coronary Artery Disease-a Systematic Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:78. [PMID: 30121850 PMCID: PMC6105244 DOI: 10.1007/s11936-018-0667-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Purpose of review Non-obstructive coronary artery disease (NOCAD) on coronary angiography is a common finding in patients with stable angina. Angina in NOCAD patients is thought to be caused by endothelial dysfunction of the epicardial coronary arteries and/or the microvasculature. Treatment is empiric, and 30% of patients remain symptomatic in spite of therapy. It is well known that physical exercise can improve endothelial function. The goal of this review was to assess the current literature on effects of physical exercise in NOCAD patients with angina. Therefore, a literature search was conducted to March 13, 2018 using the following search terms: syndrome X, microvascular angina, non-obstructive coronary artery disease and exercise training, cardiac rehabilitation, endothelial function. All original publications were included which examined the effect of a cardiac rehabilitation (CR) program or exercise training (ET) on patients with angina and NOCAD. Recent findings Eight studies, of which four were randomized controlled studies, examined 218 participants, 162 in an intervention and 56 in control groups. Most patients were women (97.7%). Exercise programs varied from 8 weeks to 4 months at moderate intensity and some included relaxation therapy. The studies examined the effect of CR on exercise capacity, quality of life (QoL), and perfusion defects. CR increased exercise capacity, oxygen uptake, symptom severity, and QoL. Myocardial perfusion improved. Summary CR appears to be beneficial in symptomatic patients with NOCAD, improving exercise capacity and QoL and reducing severity of symptoms and myocardial perfusion defects. Data is limited to a small number of predominantly female patients. Further larger trials are warranted to determine the optimal rehabilitation protocols and define its long-term benefits.
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Carvalho EE, Crescêncio JC, Santi GL, Oliveira LF, Schwartzmann PV, Gallo-Junior L, Marin-Neto JA, Simões MV. Physical training improves myocardial perfusion but not left ventricular function response to exercise in patients with microvascular angina. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2017; 63:302-310. [PMID: 28299921 DOI: 10.23736/s1824-4785.17.02930-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Patients with primary microvascular angina (PMA) commonly exhibit abnormal left ventricular function (LVF) during exercise, potentially owing to myocardial ischemia. Herein, we investigated in PMA patients the effect of the reduction of myocardial perfusion disorders, by using aerobic physical training, upon LVF response to exercise. METHODS Overall, 15 patients (mean age, 53.7±8.9 years) with PMA and 15 healthy controls (mean age, 51.0±9.4 years) were studied. All subjects were subjected to baseline resting and exercise ventriculography, myocardial perfusion scintigraphy (MPS), and cardiopulmonary testing. PMA group members then participated in a 4-month physical training program and were reevaluated via the same methods applied at baseline. RESULTS Baseline left ventricular ejection fraction (LVEF) determinations by ventriculography were similar for both groups (PMA, 67.7±10.2%; controls, 66.5±5.4%; P=0.67). However, a significant rise in LVEF seen in control subjects during exercise (75.3±6.2%; P=0.0001) did not materialize during peak exercise in patients with PMA (67.7±10.2%; P=0.47). Of the 12 patients in the PMA group who completed the training program, 10 showed a significant reduction in reversible perfusion defects during MPS. Nevertheless, LVEF at rest (63.5±8.7%) and at peak exercise (67.3±15.9%) did not differ significantly (P=0.30) in this subset. CONCLUSIONS In patients with PMA, reduced left ventricular inotropic reserve observed during exercise did not normalize after improving myocardial perfusion through aerobic physical training.
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Affiliation(s)
- Eduardo E Carvalho
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Júlio C Crescêncio
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Giovani L Santi
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Luciano F Oliveira
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Pedro V Schwartzmann
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Lourenço Gallo-Junior
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - José A Marin-Neto
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Marcus V Simões
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil -
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Current Diagnostic and Therapeutic Strategies in Microvascular Angina. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2014; 3:30-37. [PMID: 25685641 DOI: 10.1007/s40138-014-0059-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Microvascular angina is common among patients with signs and symptoms of acute coronary syndrome and is associated with an increased risk of cardiovascular and cerebrovascular events. Unfortunately, microvascular is often under-recognized in clinical settings. The diagnosis of microvascular angina relies on assessment of the functional status of the coronary microvasculature. Invasive strategies include acetylcholine provocation, intracoronary Doppler ultrasound, and intracoronary thermodilution; noninvasive strategies include cardiac positron emission tomography (PET), cardiac magnetic resonance, and Doppler echocardiography. Once the diagnosis of microvascular angina is established, treatment is focused on improving symptoms and reducing future risk of cardiovascular and cerebrovascular events. Pharmacologic options and lifestyle modifications for patients with microvascular angina are similar to those for patients with coronary artery disease.
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