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Updated: May 22, 2025
Intracoronary Acetylcholine Provocation Testing for Assessment of Coronary Vasomotor Disorders
Published on: August 18, 2016
Prognostic significance of individual COVADIS criteria in patients undergoing acetylcholine provocation testing
Riccardo Rinaldi1,2, Michele Russo2,3, Ilaria Torre2
1Cardiology Unit, Infermi Hospital, Rimini, Italy.
Insights
The prognostic significance of Coronary Vasomotor Disorders International Study Group (COVADIS) criteria in patients with myocardial ischemia and non-obstructive coronary arteries is best assessed by analyzing individual components rather than a simple positive/negative stratification. This approach offers improved prognostic stratification and personalized treatment strategies.
Area of Science:
- Cardiology
- Diagnostic Testing
- Clinical Prognosis
Background:
- The prognostic value of Coronary Vasomotor Disorders International Study Group (COVADIS) criteria during acetylcholine (ACh) provocation testing remains uncertain.
- Patients with INOCA (ischemia with non-obstructive coronary arteries) or MINOCA (myocardial infarction with non-obstructive coronary arteries) often undergo ACh testing.
Purpose of the Study:
- To evaluate the prognostic impact of COVADIS criteria in patients with INOCA or MINOCA undergoing ACh provocation testing.
- To determine if a comprehensive analysis of COVADIS criteria components improves outcome prediction.
Main Methods:
- Consecutive INOCA and MINOCA patients undergoing ACh provocation testing were enrolled.
- The presence of individual COVADIS criteria was recorded.
- Major adverse cardiovascular and cerebrovascular events (MACCE) were tracked for primary outcome assessment.
Main Results:
- Among 519 patients, 52.8% had a positive ACh test. MACCE incidence increased with the number of positive COVADIS criteria (0 criteria: 3.1%; 1: 9.2%; 2: 10.3%; 3: 15.4%).
- Patients with one or more positive criteria had significantly higher MACCE rates (12.5% vs 3.1%).
- Epicardial coronary diameter reduction ≥90% and MINOCA were independent MACCE predictors. In negative ACh tests, ≥90% diameter reduction was the sole predictor, with ≥1 COVADIS criteria indicating higher MACCE risk.
Conclusions:
- The study challenges a binary (positive/negative) interpretation of COVADIS criteria.
- A detailed analysis of individual COVADIS criteria components provides superior prognostic stratification.
- Personalized treatment strategies can be enhanced by this comprehensive approach.
Background:
The prognostic significance of the Coronary Vasomotor Disorders International Study Group (COVADIS) criteria during acetylcholine (ACh) provocation testing is uncertain.
Aims:
The aim of this study was to assess the prognostic impact of COVADIS criteria in patients with myocardial ischaemia (INOCA) or myocardial infarction (MINOCA) and non-obstructive coronary arteries undergoing ACh provocation testing.
Methods:
We enrolled consecutive INOCA and MINOCA patients undergoing ACh provocation testing. The occurrence of each COVADIS criterion was recorded. The primary outcome was the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) at follow-up.
Results:
Among 519 patients (346 [66.7%] INOCA and 173 [33.3%] MINOCA), 274 (52.8%) exhibited a positive ACh test. Over a median 22-month follow-up, the highest incidence of MACCE occurred in patients with 3 positive criteria (15.4%), followed by those with 2 (10.3%) and 1 (9.2%), while the lowest incidence occurred in patients with 0 (3.1%; p=0.004). Patients with ≥1 positive criteria had significantly higher MACCE rates than those with 0 (12.5% vs 3.1%; p=0.003). MACCE-free survival differed significantly among the four groups, with the best survival for 0 criteria and the worst for 3 (p=0.004). Epicardial coronary diameter reduction ≥90% and MINOCA were independent MACCE predictors. Among patients with a negative test, an epicardial coronary diameter reduction ≥90% was the only independent predictor of MACCE, and the presence of ≥1 criteria in this group was associated with a significantly higher MACCE rate compared to patients without any criteria.
Conclusions:
Our findings challenge the binary stratification (positive vs negative) of COVADIS criteria, suggesting an added value of a comprehensive analysis of their components to provide prognostic stratification and personalised treatment.
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