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Ischemia With Nonobstructive Coronary Arteries: Insights From the ISCHEMIA Trial
Harmony R Reynolds1, Ariel Diaz2, Derek D Cyr3
1New York University Grossman School of Medicine, New York, New York, USA.
Insights
Ischemia with nonobstructive coronary arteries (INOCA) affects 13% of patients with moderate to severe ischemia. Female sex is a key predictor, but ischemia severity does not correlate with atherosclerosis extent in INOCA patients.
Area of Science:
- Cardiology
- Medical Imaging
- Clinical Research
Background:
- Ischemia with nonobstructive coronary arteries (INOCA) is a common clinical finding, especially in women.
- The prevalence of INOCA among patients with moderate to severe ischemia and its relation to atherosclerosis severity were previously unknown.
Purpose of the Study:
- To determine the prevalence of INOCA in patients with moderate or severe ischemia.
- To identify predictors of INOCA, including sex differences.
- To examine the relationship between ischemia severity and non-obstructive atherosclerosis severity in INOCA patients.
Main Methods:
- Analysis of nonrandomized participants from the ISCHEMIA trial with moderate or severe ischemia and interpretable coronary computed tomography angiography (CCTA).
- INOCA defined as <50% stenosis on CCTA with moderate or severe ischemia on stress testing.
- Comparison of INOCA patients with randomized participants with obstructive coronary artery disease.
Main Results:
- 13% of participants (476 of 3,612) had INOCA.
- INOCA patients were younger, predominantly female, and had fewer atherosclerosis risk factors.
- Female sex was independently associated with INOCA (OR 4.2).
- No significant relationship was found between ischemia severity and non-obstructive atherosclerosis severity.
Conclusions:
- The prevalence of INOCA in patients with moderate to severe ischemia is 13%.
- Ischemia severity is not associated with the severity of non-obstructive atherosclerosis.
- Female sex is a significant independent predictor of INOCA.
Background:
Ischemia with nonobstructive coronary arteries (INOCA) is common clinically, particularly among women, but its prevalence among patients with at least moderate ischemia and the relationship between ischemia severity and non-obstructive atherosclerosis severity are unknown.
Objectives:
The authors investigated predictors of INOCA in enrolled, nonrandomized participants in ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), sex differences, and the relationship between ischemia and atherosclerosis in patients with INOCA.
Methods:
Core laboratories independently reviewed screening noninvasive stress test results (nuclear imaging, echocardiography, magnetic resonance imaging or nonimaging exercise tolerance testing), and coronary computed tomography angiography (CCTA), blinded to results of the screening test. INOCA was defined as all stenoses <50% on CCTA in a patient with moderate or severe ischemia on stress testing. INOCA patients, who were excluded from randomization, were compared with randomized participants with ≥50% stenosis in ≥1 vessel and moderate or severe ischemia.
Results:
Among 3,612 participants with core laboratory-confirmed moderate or severe ischemia and interpretable CCTA, 476 (13%) had INOCA. Patients with INOCA were younger, were predominantly female, and had fewer atherosclerosis risk factors. For each stress testing modality, the extent of ischemia tended to be less among patients with INOCA, particularly with nuclear imaging. There was no significant relationship between severity of ischemia and extent or severity of nonobstructive atherosclerosis on CCTA. On multivariable analysis, female sex was independently associated with INOCA (odds ratio: 4.2 [95% CI: 3.4-5.2]).
Conclusions:
Among participants enrolled in ISCHEMIA with core laboratory-confirmed moderate or severe ischemia, the prevalence of INOCA was 13%. Severity of ischemia was not associated with severity of nonobstructive atherosclerosis. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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