Coronary vasomotor dysfunction and anesthesia management in noncardiac surgery

Area of Science:

• Cardiology
• Anesthesiology
• Vascular Biology

Background:

• Angina with nonobstructive coronary arteries (ANOCA) is an underdiagnosed condition.
• Coronary vasomotor dysfunction (CVDys) underlies ANOCA, encompassing endothelial dysfunction, epicardial and microvascular spasm, and coronary microvascular dysfunction.
• CVDys affects a significant portion of patients with angina, with up to 40% having ANOCA.

Purpose of the Study:

• To review the pathophysiology, clinical presentation, diagnosis, and treatment of CVDys.
• To provide anesthesiologists with phenotype-guided recommendations for managing patients with ANOCA undergoing noncardiac surgery.
• To synthesize current knowledge on CVDys for improved patient care.

Main Methods:

• Review of current literature on ANOCA and CVDys.
• Synthesis of knowledge on CVDys pathophysiology, presentation, diagnosis, and treatment.
• Development of phenotype-guided anesthetic recommendations for preoperative, intraoperative, and postoperative care.

Main Results:

• CVDys is identifiable in most ANOCA patients and linked to increased mortality and major adverse cardiovascular events.
• Guidelines recommend noninvasive and invasive testing for endotype definition and tailored therapies (statins, ACE inhibitors, beta-blockers, calcium channel blockers).
• Perioperative strategies include symptom stability, hemodynamic control, stress reduction, and continuation of antianginal therapy.

Conclusions:

• CVDys is more common in females, often presenting with atypical symptoms, delayed diagnosis, and reduced quality of life.
• A structured anesthetic approach focusing on hemodynamic stability, spasm avoidance, euvolemia, and stress reduction is crucial.
• Early recognition of ischemic symptoms and collaboration with cardiology can reduce perioperative ischemic events in this population.