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Beyond the Obstructive Paradigm: Unveiling the Complex Landscape of Nonobstructive Coronary Artery Disease
Andreea Tudurachi1, Larisa Anghel1,2, Bogdan-Sorin Tudurachi1,2
1Cardiology Department, Cardiovascular Diseases Institute "Prof. Dr. George I. M. Georgescu", 700503 Iași, Romania.
Insights
Nonobstructive coronary artery disease (CAD) is common in patients with angina. This review highlights the need for new diagnostic and treatment strategies for this under-recognized condition.
Area of Science:
- Cardiology
- Vascular Medicine
Background:
- Obstructive atherosclerosis has historically dominated cardiac research.
- Up to 70% of patients with angina show no significant coronary stenoses on angiography.
- Nonobstructive coronary artery disease (CAD) is a prevalent clinical phenotype.
Purpose of the Study:
- To review the prevalence and pathophysiology of nonobstructive CAD.
- To highlight the limitations of current treatments for obstructive CAD.
- To advocate for revised diagnostic and therapeutic approaches for nonobstructive CAD.
Main Methods:
- Review of current literature on nonobstructive CAD.
- Focus on conditions like Angina with No Obstructive Coronary Artery Disease (ANOCA), Ischemia with No Obstructive Coronary Artery Disease (INOCA), and Myocardial Infarction with No Obstructive Coronary Arteries (MINOCA).
- Analysis of pathophysiology, including microvascular dysfunction and coronary vasoreactivity.
Main Results:
- Nonobstructive CAD is the most common phenotype in cardiac patients.
- Microvascular dysfunction and impaired coronary vasoreactivity are key contributors to ischemia.
- Current treatments are often inadequate as they target obstructive lesions.
Conclusions:
- A paradigm shift in diagnosing and managing nonobstructive CAD is necessary.
- Tailored therapies addressing microvascular and immunoinflammatory pathways are required.
- Improved identification and management of this prevalent patient subset are crucial.
Abstract:
Traditionally focused on obstructive atherosclerosis, contemporary research indicates that up to 70% of patients undergoing coronary angiography for angina and ischemic symptoms do not exhibit significant stenoses. Nonobstructive coronary artery disease (CAD) has emerged as a prevalent phenotype among these patients. This review emphasizes the emerging understanding that nonobstructive coronary artery disease, encompassing conditions such as ANOCA (Angina with No Obstructive Coronary Artery Disease), INOCA (Ischemia with No Obstructive Coronary Artery Disease), and MINOCA (Myocardial Infarction with No Obstructive Coronary Arteries), represents the most prevalent phenotype in cardiac patients. It delves into the complex pathophysiology underlying these conditions, focusing on microvascular dysfunction and coronary vasoreactivity, which contribute to myocardial ischemia despite the absence of significant coronary obstructions. Additionally, the review critically examines the limitations of current treatments which primarily target obstructive lesions and underscores the necessity for tailored therapies that address the specific microvascular and immunoinflammatory pathways involved in nonobstructive CAD. The main focus of this review is to advocate for a shift in diagnostic and therapeutic strategies to better identify and manage this widely prevalent yet under-recognized subset of CAD.
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