Coronary function testing to diagnose women with angina and nonobstructive coronary arteries

In a retrospective observational study among women with known or suspected ischemic heart disease, coronary angiography only revealed the anatomic diagnosis, whereas coronary function testing was often able to identify the underlying vasomotor phenotype.

This summary is based on the publication of Cigarroa N, Latif N, Maayah M, et al. - Diagnostic Yield and Clinical Utility of Coronary Angiography Versus Coronary Function Testing in Women With Angina and Nonobstructive Coronary Arteries. J Am Heart Assoc. 2024 Oct;13(19):e035852. doi: 10.1161/JAHA.124.035852

Introduction and methods

Background

More than half of the women referred for invasive coronary angiography (CA) have angina and nonobstructive coronary arteries (ANOCA) [1]. This demand and supply mismatch includes vasospastic angina, coronary microvascular dysfunction, and other coronary vasomotor disorders [2,3]. Despite clinical guideline recommendations for invasive and noninvasive testing, many patients with ANOCA do not undergo further diagnostic evaluation [4-6] and therefore miss out on appropriate treatment [7].

Aim of the study

The authors evaluated the real-world diagnostic yields of invasive coronary function testing (CFT) and coronary angiography (CA) only in women with ANOCA, as well as the changes in medical therapy following the procedures.

Methods

This was a retrospective observational cohort study in which 99 women with known or suspected ischemic heart disease who underwent clinically indicated invasive CA with CFT at Yale New Haven Hospital in New Haven, CT, USA in the period February 2018–March 2023 were included. The authors used a purposeful sampling approach to select a comparison group who underwent CA only (n=99). Exclusion criteria were CA-confirmed obstructive coronary artery disease (CAD; i.e., stenosis >50% or <50% with fractional flow reserve ≤0.80, or referral for CA for preoperative testing or evaluation of cardiomyopathy).

Outcomes

The primary endpoint was the postprocedural diagnosis. Secondary endpoints included changes in cardiac medications at 24 hours after the procedure and at 30 days.

Main results

Postprocedural diagnosis

• The CA-based diagnosis was normal coronary arteries in 21 participants (21%) in the CA only group and 48 participants (48%) in the CFT group (P<0.001). Nonobstructive CAD was diagnosed in the remaining 79% and 52%, respectively (P<0.001).

• Of the women who underwent CFT, 81 (82%) were found to have a coronary vasomotor disorder, including coronary microvascular dysfunction (27%), vasospastic angina (32%), mixed coronary microvascular dysfunction/vasospastic angina (16%), endothelial dysfunction (10%; without spasm), elevated resting flow (2%), and symptomatic myocardial bridging (4%).

Changes in cardiac medication regimen

• Within the first 24 hours, cardiac medications had been changed in 41% of the participants in the CA only group and 65% of those in the CFT group (P=0.001), whereas additional medication changes had been made by day 30 in 30% and 44%, respectively (P=0.04).

• There were no differences in the prescription of preventative medications, such as ACEis, ARBs, and statins, between the CA only and CFT groups at baseline (67% vs. 68%; P=0.88), 24 hours (74% vs. 74%; P=1.00), and 30 days (75% vs. 78%; P=0.62).

• Compared with the CA only group, antianginal therapy was intensified in the CFT group at 24 hours (79% vs. 92%; risk ratio (RR): 1.17; 95%CI: 1.04–1.31; P<0.0001) and 30 days (79% vs. 91%; RR: 1.15; 95%CI: 1.02–1.30; P=0.02).

• At baseline, fewer participants in the CA only group were prescribed calcium channel blockers compared with the CFT group (26% vs. 44%; RR: 1.69; 95%CI: 1.14–2.52; P=0.01). This significant difference was also found at 24 hours (36% vs. 63%; RR: 1.72; 95%CI: 1.27–2.33; P<0.0001) and 30 days (39% vs. 63%; RR: 1.59; 95%CI: 1.19–2.12; P<0.0001).

Conclusion

In this single-center retrospective observational cohort study among women with known or suspected ischemic heart disease, participants undergoing invasive CA only frequently received an anatomic diagnosis (nonobstructive CAD). Among the women undergoing invasive CFT instead, the underlying vasomotor phenotype was revealed in >80%. After a CFT‐confirmed diagnosis, targeted cardiac medication was changed more frequently shortly after the procedure and at 30 days compared with the CA only strategy; in particular, antianginal therapy was intensified. According to the authors, their “findings suggest that the use of coronary angiography alone (without CFT) in women with [stable ischemic heart disease] may result in underrecognition and undertreatment of underlying coronary vasomotor disorders.”

Find this article online at J Am Heart Assoc.

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