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Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
The functional assessment of patients with non-obstructive coronary artery disease: expert review from an
Robert Jay Widmer1, Bruce Samuels, Habib Samady
1Mayo Clinic Department of Cardiovascular Medicine, Rochester, MN, USA.
Insights
Symptomatic non-obstructive coronary artery disease (NOCAD) affects many patients without clear blockages. This consensus document outlines invasive methods to assess coronary flow reserve (CFR) and guide treatment for angina in these individuals.
Area of Science:
- Cardiology
- Invasive Cardiovascular Physiology
Background:
- Symptomatic non-obstructive coronary artery disease (NOCAD) is increasingly recognized, impacting cardiovascular outcomes.
- A significant proportion of patients undergoing coronary angiography for typical angina or positive stress tests lack obstructive coronary lesions.
- Current guidelines lack specific recommendations for managing patients with NOCAD.
Purpose of the Study:
- To provide a consensus-based approach for the invasive evaluation of symptomatic NOCAD patients in the cardiac catheterisation laboratory.
- To detail a stepwise method for assessing coronary physiology beyond standard angiography.
- To guide interventional cardiologists in establishing mechanisms of anginal symptoms in NOCAD.
Main Methods:
- Invasive assessment of coronary flow reserve (CFR) in the cardiac catheterisation laboratory.
- Delineation of non-endothelium-dependent CFR (CFRne) and endothelium-dependent CFR (CFRe) using provocative agents like adenosine and acetylcholine.
- Evaluation of smooth muscle function with nitroglycerine (NTG).
Main Results:
- A structured invasive approach can identify the physiologic deficiencies underlying anginal symptoms in NOCAD.
- Assessment of CFR, CFRne, and CFRe provides valuable diagnostic information.
- Understanding the mechanism allows for tailored treatment strategies.
Conclusions:
- Comprehensive invasive assessment of coronary physiology is crucial for managing symptomatic NOCAD.
- This approach enables targeted therapies for patients with non-obstructive coronary artery disease.
- Interventional cardiologists require understanding of these techniques for optimal patient care.
Abstract:
Symptomatic non-obstructive coronary artery disease (NOCAD) is an increasingly recognised entity that is associated with poor cardiovascular outcomes. Nearly half of those undergoing coronary angiography for appropriate indications, such as typical angina, or a positive stress test have no obstructive lesion. There are no guideline recommendations as to how to care properly for these patients. Physiologic assessment of the coronary arteries beyond two-dimensional angiography is not standardised, yet it can provide valuable information in patients presenting with typical angina in the setting of NOCAD. In this consensus document, we detail steps for the interventional cardiologist to evaluate the patient with symptomatic NOCAD in the cardiac catheterisation laboratory, first with the assessment of coronary flow reserve (CFR), and then with delineation of deficiencies in non-endothelium-dependent CFR (CFRne) versus endothelium-dependent CFR (CFRe) using provocative agents such as adenosine and acetylcholine, respectively, followed by the evaluation of smooth muscle function with nitroglycerine (NTG). Once the mechanism behind the anginal symptoms is established, one can identify the appropriate treatment strategies to address the physiologic deficiency that is present. Despite an established safety profile, a comprehensive assessment may be considered for selected patients which requires an understanding of the appropriate invasive evaluation by the practising interventional cardiologist when evaluating not only patients with obstructive CAD but also those with NOCAD.
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