A focus on the prognosis and management of ischemic heart disease in patients without evidence of obstructive coronary artery disease

Abstract

Ischemic heart disease without evidence of obstructive coronary artery disease is a common phenotype comprising different coronary syndromes with either stable or unstable clinical presentation. In this context, the clinical outcome and management appear extremely variable, due to different etiologies. Of note, coronary microvascular dysfunction is the pathogenetic mechanism linking different clinical scenarios in most of the cases. Hence, in this article, we aim to provide a systematic approach of reviewing the prognosis and management of angina or myocardial infarction without evidence of obstructive coronary artery disease. Moreover, we will propose a new scheme of classification by distinguishing between angina with normal coronary artery and myocardial infarction with normal coronary artery in order to facilitate clinicians to perform a proper management workflow.

Keywords:

• coronary microvascular dysfunction
• myocardial disease
• myocardial infarction with no obstructive coronary atherosclerosis
• primary microvascular angina

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Myocardial ischemia with anginal symptoms but without evidence of obstructive coronary artery disease (CAD) is an emerging entity embracing different clinical scenario.

• Coronary microvascular dysfunction represents the pathogenetic mechanism linking such different clinical scenarios.

• The prognosis and therapy vary according to the specific cause and stable and unstable presentation.

• Our scheme of classification distinguishes between angina and myocardial infarction (MI) without evidence of obstructive CAD (ANOCA and MINOCA, respectively).

• ANOCA includes primary microvascular angina or angina associated with myocardial disease and it is essentially based on type 1 and 2 of the Camici-Crea classification.

• Myocardial diseases included in ANOCA embrace hypertrophic cardiomyopathy, dilated cardiomyopathy, infiltrative diseases and aortic stenosis.

• MINOCA is a type I MI, including epicardial (coronary artery spasm and positive remodeling of unstable plaque but no obstructive atherosclerosis) and microvascular causes (Takotsubo syndrome, coronary microvascular spasm, myocarditis mimicking MI and coronary embolism).

• The prognosis of ANOCA (e.g., stable primary microvascular angina) is good and the main aim of the clinician is to improve quality of life by controlling anginal symptoms.

• The prognosis of MINOCA is complex and requires appropriate secondary prevention strategies focused on recurrence of cardiac events.

Notes