Diagnostic approach in patients with angina and no obstructive coronary artery disease: emphasising the role of the coronary function test.

R E Konst,S E Elias-Smale,D Pellegrini,N Van Royen,P Damman,A H E M Maas

doi:10.1007/s12471-020-01532-9

Abstract

BackgroundMany patients with angina do not have obstructive coronary artery disease (CAD), also referred to as “Ischaemia with No Obstructive Coronary Arteries“ (INOCA). Coronary vascular dysfunction is the underlying cause of this ischaemic heart disease in as much as 59–89% of these patients, including the endotypes of coronary microvascular dysfunction and epicardial coronary vasospasm. Currently, a coronary function test (CFT) is the only comprehensive diagnostic modality to evaluate all endotypes of coronary vascular dysfunction in patients with INOCA.ObjectiveIn this paper we discuss the relevance of performing a CFT, provide considerations for patient selection, and present an overview of the procedure and its safety.MethodsWe reviewed the latest published data, guidelines and consensus documents, combined with a discussion of novel original data, to present this point of view.ResultsThe use of a CFT could lead to a more accurate and timely diagnosis of vascular dysfunction, identifies patients at risk for cardiovascular events, and enables stratified treatment which improves symptoms and quality of life. Current guidelines recommend considering a CFT in patients with INOCA and persistent symptoms. The safety of the procedure is comparable to that of a regular coronary angiography with physiological measurements. Non-invasive alternatives have limited diagnostic accuracy for the identification of coronary vascular dysfunction in patients with INOCA, and a regular coronary angiography and/or coronary computed tomography scan cannot establish the diagnosis.ConclusionsA complete CFT, including acetylcholine and adenosine tests, should be considered in patients with INOCA.Supplementary InformationThe online version of this article (10.1007/s12471-020-01532-9) contains supplementary material, which is available to authorized users.

Highlights

Obstructive coronary artery disease (CAD) is the bestknown cause of ischaemic heart disease (IHD)
With current evidence and in line with current Dutch recommendations [15], performing a coronary function test (CFT) should be considered in the following situations: If establishing a definite diagnosis of vascular dysfunction is important for the treating physician, for example to aid tailored treatment when different anti-anginal agents are unsuccessful in improving the anginal symptoms in the patient with Ischaemia with No Obstructive Coronary Arteries (INOCA) [17]
The key message is that an invasive CFT is a feasible, useful and safe method to identify coronary vascular dysfunction in patients with INOCA

Summary

Results

The use of a CFT could lead to a more accurate and timely diagnosis of vascular dysfunction, identifies patients at risk for cardiovascular events, and enables stratified treatment which improves symptoms and quality of life. Current guidelines recommend considering a CFT in patients with INOCA and

Introduction

Transient ischaemic ECG changes during spontaneous

Conclusions and future perspectives