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Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Feasibility and Impact of Invasive Coronary Function Testing in Ischemia and No Obstructive Coronary Arteries: A
Deeksha Acharya1, Yulith Roca Alvarez1, Bruce Samuels2
1Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
Insights
Coronary function testing (CFT) is feasible and safe for diagnosing ischemia and no obstructive coronary arteries (INOCA). CFT results guided medication changes in patients with coronary microvascular disease and vasospastic angina.
Area of Science:
- Cardiology
- Diagnostic Testing
- Vascular Medicine
Background:
- Ischemia and no obstructive coronary arteries (INOCA) presents a diagnostic challenge.
- Coronary function testing (CFT) aids in identifying INOCA endotypes but faces limited adoption.
- Understanding CFT feasibility and its clinical impact is crucial for improving patient management.
Purpose of the Study:
- To assess the feasibility and safety of implementing CFT in a clinical setting.
- To evaluate the impact of CFT results on medical management strategies for INOCA patients.
- To determine the diagnostic yield of CFT in stratifying INOCA patients into specific endotypes.
Main Methods:
- A single-center, prospective study evaluated CFT implementation and medication adjustments.
- Interventional cardiologists rated CFT feasibility, preparation, support, and diagnostic value via surveys.
- Patients were categorized into coronary microvascular disease (CMD), vasospastic angina (VA), mixed disease (MD), or no vasomotor diagnosis based on CFT results.
- Medication use was compared at baseline and 30 days post-CFT.
Main Results:
- High ratings (98%) for CFT feasibility, preparation, and diagnostic value were reported by cardiologists.
- The mean procedural time for CFT was 19 minutes and 7 seconds, with a 14% self-limited adverse event rate.
- CFT identified CMD in 60.6%, VA in 26.8%, and MD in 22.5% of patients.
- CMD patients showed increased ACE inhibitor/ARB and statin use; VA patients showed increased CCB use post-CFT.
Conclusions:
- Coronary function testing (CFT) is highly feasible, safe, and clinically valuable for INOCA patients.
- CFT implementation successfully guided medication management adjustments for specific INOCA endotypes.
- The study supports broader adoption of CFT for precise diagnosis and tailored treatment in INOCA.
Background:
In patients with suspected ischemia and no obstructive coronary arteries (INOCA), coronary function testing (CFT) helps identify underlying endotypes. Despite guideline support, adoption of CFT remains limited. This study assessed the feasibility of CFT and its impact on medical management.
Methods:
This single-center, prospective study (2020-2025) evaluated CFT implementation and subsequent medication changes in patients with clinically indicated CFT. Interventional cardiologists completed postprocedure surveys rating CFT feasibility, preparation, lab support, and diagnostic value. CFT results were categorized into coronary microvascular disease (CMD), (coronary flow reserve <2.5 in response to adenosine and/or endothelial dysfunction indicated by abnormal epicardial coronary response to acetylcholine without evidence of ischemia); vasospastic angina (VA)-ischemic ECG changes with or without angina in response to acetylcholine together with either: (1) epicardial VA (>75% epicardial constriction), or (2) microvascular VA (<75% epicardial constriction); mixed disease (MD) (CMD and VA), and no vasomotor diagnosis (no CMD or VA). Medication use was compared at baseline and 30 days after CFT.
Results:
Five of the 10 interventional cardiologists completed 71 surveys. Overall, 98% rated preparation, training, procedural ease, and diagnostic value as "above average" and would recommend CFT to peers. Mean procedural time was 19 minutes, 7 seconds. There were 10 (14%) adverse events, of which 90% were self-limited. Among 71 patients, 60.6% had CMD, 26.8% VA, and 22.5% MD. CMD patients showed increased angiotensin converting enzyme inhibitor/angiotensin receptor blocker use (39.5% to 55.8%, P = .008) and statin use (53.5% to 65.1%, P = .02). VA patients had increased calcium channel blocker use (68.4% to 89.5%, P = .10). MD and no vasomotor diagnosis had no significant medication changes.
Conclusions:
CFT was rated highly for feasibility, safety, and clinical value by the interventional cardiologists. CFT appeared to impact the medication management of INOCA endotypes.
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