Insights to advance our management of myocardial ischemia: From obstructive epicardial disease to functional coronary alterations

C Noel Bairey Merz; John F Beltrame; Colin Berry; William E Boden; Paolo G Camici; Filippo Crea; Judith S Hochman; Juan Carlos Kaski; Patrick T O'Gara; Peter Ong; Carl J Pepine; Hiroaki Shimokawa; Udo Sechtem; Gregg W Stone

doi:10.1016/j.ahjo.2021.100060

Insights to advance our management of myocardial ischemia: From obstructive epicardial disease to functional coronary alterations

Am Heart J Plus. 2021 Oct 8:11:100060. doi: 10.1016/j.ahjo.2021.100060. eCollection 2021 Nov.

Authors

C Noel Bairey Merz¹, John F Beltrame², Colin Berry^{3

4}, William E Boden⁵, Paolo G Camici⁶, Filippo Crea⁷, Judith S Hochman⁸, Juan Carlos Kaski⁹, Patrick T O'Gara¹⁰, Peter Ong¹¹, Carl J Pepine¹², Hiroaki Shimokawa¹³, Udo Sechtem¹¹, Gregg W Stone^{14

15}

Affiliations

¹ Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
² The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network, Adelaide, South Australia, Australia.
³ West of Scotland Regional Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK.
⁴ British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK.
⁵ VA New England Health Care System, Massachusetts Veterans Epidemiology, Research, and Informatics Center, Boston University School of Medicine, Boston, MA, USA.
⁶ Vita Salute University, San Raffaele Hospital, Milan, Italy.
⁷ Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy.
⁸ New York University Grossman School of Medicine, New York, NY, USA.
⁹ Cardiovascular and Cell Sciences Research Institute, St George's, University of London, London, UK.
¹⁰ Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹¹ Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
¹² Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA.
¹³ Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
¹⁴ Division of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
¹⁵ Cardiovascular Research Foundation, New York, NY, USA.

Abstract

Study objective: The Coronary Vasomotor Disorders International Study Group (COVADIS) invited leading experts to address strategies to enhance our clinical understanding of INOCA with an emphasis on the management of coronary vasomotor disorders.

Design: Under-recognition of coronary vasomotor disorders, distinguishing different presentations of angina due to vasospasm and/or abnormal microvascular vasodilatation, developing invasive/non-invasive testing and treatment protocols, integrating diagnostic protocols into cardiologists' workflow and trials to inform guideline development were identified as key knowledge gaps and will be briefly addressed in this Viewpoint article.

Setting: Virtual international meeting.

Participants: Leading international experts in ischemic heart disease with no obstructive coronary artery disease.

Interventions: None.

Main outcome measures: None.

Results: Topics discussed include: 1. Obstructive epicardial disease, functional vasospasm and microvascular disorders; 2. Under-recognition of coronary vasomotor disorders in clinical practice; 3. Complexity of coronary vasomotor disorders; 4. Understanding different presentations - vasospastic disease and microvascular angina; 5. Invasive/noninvasive testing and treatment protocols for vasospasm and microvascular angina assessment; 6. Treatment challenges; 7. Integrating diagnostic protocols into cardiologists' workflow; 8. The path forward to advance our approach to managing myocardial ischemia.

Conclusions: Obstructive epicardial disease, functional vasospasm and microvascular disorders often co-exist and contribute to myocardial ischemia. Under-recognition, the complexity of coronary vasomotor disorders, understanding different presentations, testing and treatment protocols, treatment challenges, and integrating diagnostic protocols into cardiologists' workflow all contribute to the path forward to advance our management of myocardial ischemia for improved patient outcomes.

Keywords: Coronary artery disease; Coronary microvascular dysfunction; Microvascular angina; Myocardial ischemia with no obstructive CAD (INOCA); Vasospastic angina.