Ischemia but no obstructive coronary artery disease: more than meets the eye

Abstract

Symptomatic women with angina are more likely to have ischemia with no obstructive coronary arteries (INOCA) compared to men. In both men and women, the finding of INOCA is not benign and is associated with adverse cardiovascular events, including myocardial infarction, heart failure and angina hospitalizations. Women with INOCA have more angina and a lower quality of life compared to men, but they are often falsely reassured because of a lack of obstructive coronary artery disease (CAD) and a perception of low risk. Coronary microvascular dysfunction (CMD) is a key pathophysiologic contributor to INOCA, and non-invasive imaging methods are used to detect impaired microvascular flow. Coronary vasospasm is another mechanism of INOCA, and can co-exist with CMD, but usually requires invasive coronary function testing (CFT) with provocation testing for a definitive diagnosis. In addition to traditional heart disease risk factors, inflammatory, hormonal and psychological risk factors that impact microvascular tone are implicated in INOCA. Treatment of risk factors and use of anti-atherosclerotic and anti-anginal medications offer benefit. Increasing awareness and early referral to specialized centers that focus on INOCA management can improve patient-oriented outcomes. However, large, randomized treatment trials to investigate the impact on major adverse cardiovascular events (MACE) are needed. In this focused review, we discuss the prevalence, pathophysiology, presentation, diagnosis and treatment of INOCA.

摘要

与男性相比, 有症状的女性心绞痛更有可能出现无阻塞性冠状动脉缺血(INOCA)。在男性和女性中, INOCA的发现都不是良性的, 并与不良心血管事件相关, 包括心肌梗死、心力衰竭和心绞痛住院。与男性相比, 患有INOCA的女性患心绞痛的几率更高, 生活质量也较低, 但她们常常因为没有阻塞性冠状动脉疾病(CAD)而被错误地确定下来, 并被认为风险较低。冠状动脉微血管功能障碍(CMD)是一个关键的病理生理学因素, 并采用无创成像方法检测微血管血流受损。冠状动脉痉挛是INOCA的另一机制, 可与CMD共存, 但通常需要有创冠状动脉功能检测(CFT)和激发性检测才能确诊。除了传统的心脏病危险因素外, 影响微血管张力的炎症、激素和心理危险因素也与INOCA有关。治疗危险因素和使用抗动脉粥样硬化和抗心绞痛药物是有益的。提高意识和早期转诊到专注于INOCA管理的专科中心可以改善以患者为导向的结果。然而, 需要进行大型随机治疗试验来研究主要不良心血管事件(MACE)的影响。在这篇综述中, 我们讨论了INOCA的流行、病理生理、表现、诊断和治疗。

Keywords:

• Myocardial ischemia
• endothelial dysfunction
• microvascular angina
• heart disease in women

Acknowledgements

The authors acknowledge Esha Dave, MS for help with the figures for this manuscript. All figures were created using Biorender.com.

Potential conflict of interest

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported, in part, by a developmental grant on Specialized Center of Research Excellence in Sex Differences (SCORE) from the National Institutes of Health [1U54AG062334-01], [1R01HL157311]; and Mrs Marcia Taylor.