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Understanding INOCA: Ischemia With No Obstructive Coronary Artery Disease
- 1. INOCA Mentor : Dr. Debanik Chaudhuri Presenter: Ashwini k Ashwath
- 2. Introduction - What exactly is INOCA? - Why do some people with positive nuclear stress test have non-obstructive CAD? - Why was the nuclear stress positive?
- 5. Patients with ischemia and no obstructive coronary artery disease have similar angina burden but worse quality of life than obstructive coronary artery disease subjects.
- 6. Background • Prevalence : 3-4 million in American population, among the patients with stable angina, 65% had INOCA. • Patient population : - Women (65% in women Vs 32% in men) , - Rheumatological disorders, - Malignancies, - Drug use, - infiltrative disorders (amyloidosis, sarcoidosis)
- 7. CFR, coronary flow reserve; CT, computed tomography; FFR, fractional flow reserve; hMR, hyperaemic microvascular resistance; hSR, hyperaemic stenosis resistance; iFR, instantaneous wave-free ratio; IMR, index of microvascular resistance; NHPR, non-hyperaemic pressure ratio; Pd/Pa, resting distal to aortic pressure ratio; QFR, quantitative flow reserve. Copyright © 2021, Oxford University Press
- 8. FFR: fractional flow reserve, iFR: instantaneous wave-free ratio, Pd: distal coronary pressure, Pa: proximal coronary pressure, HSR: hyperaemic stenosis resistance, BSR: basal stenosis resistance, IMR: index of microcirculatory resistance, HMR: hyperaemic microvascular resistance. Al-Obaidi FR, Fearon WF, Yong ASC. Invasive physiological indices to determine the functional significance of coronary stenosis. Int J Cardiol Heart Vasc. 2018 Feb 23;18:39-45. doi: 10.1016/j.ijcha.2018.02.003. PMID: 29876502; PMCID: PMC5988484.
- 9. ACC/AHA, American College of Cardiology/American Heart Association; ACS, actue coronary syndrome CCS, chronic coronary syndrome; CFR, coronary flow reserve; FFR, fractional flow reserve; hMR, hyperaemic microvascular resistance; hSR, hyperaemic stenosis resistance; IMR, index of microvascular resistance; iFR, instantaneous flow reserve; NHPR, non-hyperaemic pressure ratio. Copyright © 2021, Oxford University Press
- 10. © 2018 Published by Elsevier on behalf of the American College of Cardiology Foundation.
- 11. © 2018 Published by Elsevier on behalf of the American College of Cardiology Foundation.
- 12. © 2018 Published by Elsevier on behalf of the American College of Cardiology Foundation.
- 13. How does this make any difference? - more accurate treatment - less polypharmacy - lesser preventable adverse events such as hospitalisations due to AKI ( from ACE/ARB), syncopes, bradycardias. - better compliance ( with lesser medications) - Enhanced quality of life.
- 14. Take home points • Don’t dismiss any non-obstructive coronary artery disease as Non- cardiac chest pain. • Especially in women & rheumatological disorders, we all know that they present with atypical chest pain symptoms and most likely to have INOCA rather than Obstructive CAD so, keep your mind open.
- 15. References • Romana Herscovici, MD; Tara Sedlak, MD; Janet Wei, MD; Carl J. Pepine, MD; Eileen Handberg, PhD, ARNP; C. Noel Bairey Merz, MD.Ischemia and No Obstructive Coronary Artery Disease (INOCA): What Is the Risk? Originally published24 Aug 2018https://doi.org/10.1161/JAHA.118.008868Journal of the American Heart Association. 2018;7:e008868 • Paul D. Morris, Nick Curzen and Julian P. Gunn. Angiography‐Derived Fractional Flow Reserve: More or Less Physiology? Originally published11 Mar2020https://doi.org/10.1161/JAHA.119.015586Journal of the American Heart Association. 2020;9:e015586 • Daniel Tze Yee Ang 1,2 and Colin Berry 1,2 1. What an Interventionalist Needs to Know About INOCA. Interventional Cardiology 2021;16:e32. DOI: https://doi.org/10.15420/icr.2021.16 • Wang ZJ, Zhang LL, Elmariah S, Han HY, Zhou YJ. Prevalence and Prognosis of Nonobstructive Coronary Artery Disease in Patients Undergoing Coronary Angiography or Coronary Computed Tomography Angiography: A Meta-Analysis. Mayo Clin Proc. 2017 Mar;92(3):329-346. doi: 10.1016/j.mayocp.2016.11.016. PMID: 28259226. • Ford TJ, Stanley B, Sidik N, Good R, Rocchiccioli P, McEntegart M, Watkins S, Eteiba H, Shaukat A, Lindsay M, Robertson K, Hood S, McGeoch R, McDade R, Yii E, McCartney P, Corcoran D, Collison D, Rush C, Sattar N, McConnachie A, Touyz RM, Oldroyd KG, Berry C, One-Year Outcomes of Angina Management Guided by Invasive Coronary Function Testing (CorMicA), JACC: Cardiovascular Interventions (2019), doi: https://doi.org/10.1016/j.jcin.2019.11.001. • Ozan M Demir, Haseeb Rahman, Tim P van de Hoef, Javier Escaned, Jan J Piek, Sven Plein, Divaka Perera, Invasive and non- invasive assessment of ischaemia in chronic coronary syndromes: translating pathophysiology to clinical practice, European Heart Journal, Volume 43, Issue 2, 7 January 2022, Pages 105–117, https://doi.org/10.1093/eurheartj/ehab548
- 16. THANK YOU
Editor's Notes
- Good afternoon everyone, My name is Ashwini Ashwath. I will be talking about INOCA today and my mentor and advisor here is Dr. Chaudhuri. Does anyone know what INOCA is? (This sign “” indicates you should press the next arrow key during the slideshow to have accurately timed animations.) Ischemia with Non Obstructive Coronaries
- What exactly is INOCA? ..It is a syndrome of patients with either symptoms and/or signs of ischemia but found to have no obstructive coronary artery disease (CAD).3 Why do some people with positive nuclear stress test have non-obstructive CAD? You might say, may be it was non-cardiac origin, if that’s the case, Why was the Nuc stress positive? Sure there are some false positives but,….is that it?
- Lets go through some definitions to understand better First of all, what is Obstructive CAD: It is called Obstructive CAD if the stenosis is ≥50% diameter and fractional flow reserve ≤0.80 during coronary angiography. Vasospastic angina : There is reproduction of angina symptoms, ischemic ECG changes with ≥ 90% constriction in major epicardial artery. Microvascular Angina : Angina with no obstructive CAD plus objective evidence of coronary microvascular dysfunction (as defined by abnormal response to intracoronary ACh and/or systemic adenosine. CFR<2 IMR≥25 ACh response (microvascular spasm) defined by reproduction of angina, ST segment deviation (≥1 mm) and absence of significant epicardial coronary vasoconstriction during ACh (<90% epicardial constriction) Mixed microvascular and VSA: angina with no obstructive CAD plus BOTH evidence of invasive coronary microvascular dysfunction and epicardial vasospasm to ACh (≥90% epicardial constriction) Noncardiac chest pain: normal coronary vascular function Endothelial dysfunction is defined by ≥20% luminal constriction during ACh infusion (up to 10−4 M).20
- What is Microcirculation? Here, The difference you see between these two pictures is what is microcirculation. The arteries that you see on angiogram are the Epicardial arteries, the picture A and the rest of those minute arteries are nothing but microcirculation. I hope it made sense?
- You might ask, why I am focusing so much on this microvascular dysfunction? The Coronary microvascular dysfunction (CMD) doesn’t just contribute to INOCA but also in cardiomyopathies, heart failure, especially the preserved ejection fraction subtype, and also has a potential to develop into Obstructive CAD within a matter of few years, Embolisation, ACS, takotsubo syndrome and Anginal symptoms. determining myocardial ischemia in patients with angina without obstructive coronary artery disease, as well as in several other conditions, including obstructive coronary artery disease, nonischemic cardiomyopathies, takotsubo syndrome, and heart failure, especially the phenotype associated with preserved ejection fraction. Unfortunately, despite the identified pathophysiological and prognostic role of CMD in several conditions, to date, there is no specific treatment for CMD. Due to the emerging role of CMD as common denominator in different clinical phenotypes, additional research in this area is warranted to provide personalized treatments in this “garden variety” of patients. Patients with ischemia and no obstructive coronary artery disease have similar angina burden but worse quality of life than obstructive coronary artery disease subjects.
- Prevalence : 3-4 million in American population, among patients with stable angina, 65% had INOCA. Patient population : Women (65% in women Vs 32% in men) , Rheumatological disorders, Malignancies, Drug use, infiltrative disorders (amyloidosis, sarcoidosis) And the diagnosis of INOCA is mostly by Invasive coronary physiology testing which we will talk about in the next few slides.
- So, what we usually use to assessment in Cardiac cath normally is, Anatomic assessment. How much of an obstruction can we visibly see is how we assess it. That’s also the easiest and least accurate. The most accurate ones are CFR ( comprehensive physiology testing ) and FFR. Lets focus on our topic today, that is Non-obstructive CAD, the best indices for that are CFR (coronary flow reserve) & hMR (hyperaemic microvascular resistance) , IMR (index of microvascular resistance)
- The parallel lines that are mentioned as Epicardial arteries are like the name suggests are the arteries that are visible outside such as LAD, Left circumflex etc, the circle one is the microcirculation ( smaller blood vessels), the Coronary physiology testing that can assess Microvascular resistance are IMR/HMR like I mentioned before and CFR but….. FFR ( Fractional Flow Reserve ) is the gold standard.
- This is again the summary of the coronary artery indices, FFR is validated in large population and is cost effective but it cannot assess microvascular dysfunction. There is IMR but that doesn’t assess Epicardial stenosis. So we have CFR, which measures both. You don’t have to remember all of this as long as you remember coronary physiology studies, that is more than enough.
- This Figure is illustrating 3 cases with similar baseline angiograms showing no obstructive epicardial coronary artery disease. Each case reveals distinct diagnoses (endotypes) with different therapy guided by the Invasive physiology results. The blue figure shows a typical case of VSA ( especially vasospasm in the epicardial vessels ). The patient was previously on a beta-blocker, and this was substituted for a calcium-channel blocker with smoking cessation counselling. Ach ¼ acetylcholine; CAD ¼ coronary artery disease; CFR ¼ coronary flow reserve; FFR ¼ fractional flow reserve; IDP ¼ interventional diagnostic procedure; IMR ¼ index of microcirculatory resistance; VSA ¼ vasospastic angina.
- The orange case has proven microvascular dysfunction but no severe vasospasm. There were abnormalities in both microcirculatory resistance (IMR) and coronary vasodilator reserve (CFR). Thepatient has a diagnosis of microvascular angina and had cessation of long-acting nitrate medication with up titration of beta-blocker. The patient underwent cardiac rehabilitation classes to assist in weight loss and identify relevant lifestyle factors implicated in the condition. Ach ¼ acetylcholine; CAD ¼ coronary artery disease; CFR ¼ coronary flow reserve; FFR ¼ fractional flow reserve; IDP ¼ interventional diagnostic procedure; IMR ¼ index of microcirculatory resistance; VSA ¼ vasospastic angina.
- The final patient (green) presented with anginal symptoms but no objective abnormality in coronary function. The patient was diagnosed with noncardiac chest pain, reassured, and discharged from cardiology. Ach ¼ acetylcholine; CAD ¼ coronary artery disease; CFR ¼ coronary flow reserve; FFR ¼ fractional flow reserve; IDP ¼ interventional diagnostic procedure; IMR ¼ index of microcirculatory resistance; VSA ¼ vasospastic angina.
- How does this make any difference? We hypothesize that with the testing of invasive coronary physiology measurements, one can diagnose the exact etiology and personalize medical treatment for an individual resulting in - more accurate treatment, - less polypharmacy, - lesser preventable adverse events such as hospitalisations due to AKI, - better compliance ( with lesser medications) and - Enhanced quality of life shown by Cormica Trial.
- So, for the take home points..Don’t dismiss any non-obstructive coronary artery disease as Non-cardiac chest pain, especially in women… we all know that they present with atypical chest pain symptoms and most likely to have INOCA rather than Obstructive CAD so, keep your mind open.
- Here are some references..
- THANK YOU ALL and my wonderful clinic group B! My mentor Dr. Chaudhuri, My mom and & Dad and my lovely husband.