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Effect of State-of-the-Art Treatment on Symptoms, Absolute Coronary Artery Flow, and Resistance Among Patients With
Aurelia Zimmerli1, Jeremie Buri1, Adil Salihu1
1Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
Insights
This study evaluates a new treatment strategy for coronary microvascular dysfunction (CMD) in patients with angina without obstructive coronary arteries (ANOCA/INOCA). The approach improved objective measures and patient-reported symptoms, offering a potential new management guideline.
Area of Science:
- Cardiology
- Vascular Medicine
- Pharmacology
Background:
- Coronary microvascular dysfunction (CMD) affects patients with angina but no obstructive coronary arteries (ANOCA/INOCA), leading to symptoms and reduced quality of life.
- Current evidence-based treatment strategies for ANOCA/INOCA are limited due to small, heterogeneous studies.
- A stepwise management strategy for ANOCA/INOCA has been proposed but not yet clinically evaluated for effectiveness.
Purpose of the Study:
- To assess the clinical effectiveness of a state-of-the-art, stepwise treatment algorithm for ANOCA/INOCA.
- To determine if this strategy improves invasive measures of coronary microcirculation and patient-reported symptoms.
- To provide the first prospective evaluation of this guideline-based approach in CMD.
Main Methods:
- Prospective, single-center study enrolling 40 patients with angina, ischemia, and confirmed CMD (coronary flow reserve ≤2.5).
- Sequential pharmacological therapy: Stage 1 (statins, beta-blockers, ACE inhibitors), Stage 2 (add CCB if needed), Stage 3 (add ranolazine if needed).
- Assessment of symptoms and quality of life (SAQ-19, EQ-5D-5L) and invasive hemodynamic measurements at baseline and after treatment stages.
Main Results:
- The study is designed to provide the first prospective evaluation of a sequential, guideline-based pharmacological strategy in CMD.
- It will assess both objective physiological measures and patient-centered outcomes.
- Results are anticipated to inform future guideline recommendations and improve clinical management.
Conclusions:
- The findings may support the proposed stepwise treatment algorithm for ANOCA/INOCA.
- This research could lead to improved clinical management and personalized treatment for patients with CMD.
- The study aims to advance the understanding and treatment of this understudied patient population.
Abstract:
A significant proportion of patients referred to the cardiac catheterization laboratory for ischemia and/or angina do not have obstructive coronary arteries. This condition (INOCA and/or ANOCA, respectively) is frequently associated with coronary microvascular dysfunction (CMD). CMD causes myocardial ischemia, persistent symptoms, impaired quality of life, and increased healthcare utilization. Despite its clinical relevance, evidence-based therapeutic strategies remain limited, as prior studies regarding the treatment have been small and heterogeneous. Recently, an expert consensus proposed a standardized, stepwise management strategy for ANOCA/INOCA, built on the limited evidence currently available. However, the clinical effectiveness of this therapeutic algorithm has never been evaluated, either from a subjective perspective through patient-reported symptom burden or from an objective standpoint using invasive hemodynamic measurements. This prospective, single-center study aims to evaluate whether the state-of-the-art treatment recommended by the EAPCI Expert Consensus Document improves invasive measures of coronary microcirculation and symptoms in patients with ANOCA/INOCA. A total of 40 patients with angina, and objective evidence of ischemia on non-invasive testing, and CMD confirmed by continuous intracoronary thermodilution (coronary flow reserve ≤2.5) will be enrolled. Patients will receive sequential pharmacological therapy in 3 stages: (1) statins, beta-blockers, and ACE inhibitors; (2) conditional addition of a calcium channel blocker in case of persistent angina or pathological exercise treadmill test; and (3) conditional addition of ranolazine in case of persistent angina or pathological exercise treadmill test. At baseline and after each treatment stage, symptoms and quality of life will be assessed using the Seattle Angina Questionnaire (SAQ-19) and the EuroQol-5D (EQ-5D-5L). Invasive reassessment will be performed once patients report complete symptom resolution or once the complete therapeutic algorithm has been completed. This study will provide the first prospective evaluation of a sequential, guideline-based pharmacological strategy in CMD using both objective physiological measures and patient-centered outcomes. Findings may inform future guideline recommendations, improve clinical management of ANOCA/INOCA, and advance personalized treatment approaches in this understudied population.
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