Angina Patients Without Obstructive CAD Have Worse Outcomes – Medscape

Patients with angina but no obstructive coronary artery disease (CAD) have a significantly worse treatment response and quality of life than patients with overt disease amenable to interventions, reveals UK prospective trial data.

Dr Andrew Morrow, from the University of Glasgow, and colleagues, say the results show that "angina patients without obstructive coronary disease have unmet clinical needs, and disease-modifying therapies are urgently needed".

The research was presented on August 28 at the European Society of Cardiology Congress 2020, which was held digitally due to the coronavirus pandemic.

The researchers prospectively evaluated almost 400 angina patients in the CorMicA randomised controlled clinical strategy trial, finding that almost half had ischaemia with no obstructive coronary artery disease (INOCA).

At 6 months follow-up, these patients had markedly worse angina and treatment responses than angina patients who could be treated with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery.

Moreover, they had reduced quality of life and greater psychological distress, despite having similar adverse event rates.

Professor Sir Nilesh Samani, medical director at the British Heart Foundation, which funded the study, and professor of cardiology at the University of Leicester, explained that the problem with this group of patients is that "you can't offer the conventional treatments" of stents or bypass surgery.

"Therefore these people continue to have persistent symptoms, because there isn't a specific therapy that you're offering them to relieve what you think is the cause of the symptoms," he told Medscape News UK.

"A lot of cardiologists of course like to do stents and bypass surgery and so on, and they find it much easier to treat patients when they've got something they can physically do something about.

"So there's a group of patients like this who frankly don't get the best deal, not because people don't want to do anything but because we don't understand the disease course."

He also pointed out that labelling patients as having angina when they have the typical symptoms but without having blocked arteries is "slightly problematic because there isn't an actual diagnostic test for this and that is also part of the dilemma of how best we manage them".

Prof Samani added that the issue in these patients "is not in the major blood vessels, but in the microvessels, the microcirculation of the heart, and it seems there is an issue there around the way it reacts".

Approached for comment, Steen Dalby Kristensen, professor and consultant cardiologist at Aarhus University in Skejby, Denmark, underlined that this is a small study, as highlighted by the low number of major adverse events recorded during follow-up.

He also told Medscape News UK that it is "not so surprising" that patients with overt disease that could be treated "mechanically" with PCI or CABG surgery ended up angina-free and had a better response than those who could not.

Another important consideration is that INOCA is not just one condition but "many things", and these patients "will have changes in their coronary vessels, but it might be in the smaller vessels or it might be some diffuse lesions in the bigger vessels that are not really suitable for intervention".

For him, this underlines the need to "really select your patients for angiography carefully".

Prof Kristensen nevertheless agreed with the researchers' conclusion that there is a high unmet clinical need in angina patients without obstructive CAD.

"We actually desperately need some new therapies in the field of medical treatment of angina because, to be frank, we've not had a lot of new discoveries within the last 15 or 20 years," he said.

"This is really an unmet need to try to improve therapy for these patients. I think also for many of them it might also be possible to get better by having a healthy lifestyle and taking cholesterol-lowering drugs and maybe also aspirin."

Dr Stephane Manzo-Silberman, a senior interventional cardiologist at Lariboisire Hospital Paris, France, said that this study is about recognising the impact of INOCA on patients, who can have a "similar, or even worse" prognosis than angina patients with obstructive CAD.

"It's not only a matter of mortality but also of quality of life and it is distressing," she told Medscape News UK.

She also agreed that there is a need for new 'tools' to treat INOCA and to adapt treatment approaches to improve the prognosis.

To assess the quality of life and clinical outcomes of patients with angina undergoing invasive coronary angiography, the researchers prospectively evaluated patients enrolled in a randomised clinical strategy trial.

The aim of the trial was to determine whether routine tests of small vessel function in the heart might help to identify patients with a stable coronary syndrome due to vasospastic or microvascular angina, and to rule it out in patients with normal test results, and thus to optimise treatment.

Over a period of 12 months, the team enrolled 391 patents, who had a mean age of 62 years, of whom 52% were female.

They were stratified into patients with INOCA (n=185) or those with obstructive CAD managed medically (n=32), with PCI (n=126) or with CABG surgery (n=48).

At baseline, the majority of patients had daily or weekly angina, at a mean Seattle Angina Questionnaire (SAQ) frequency score of 60, with a substantial overall angina burden, at a mean SAQ summary score of 52.5.

Scores were similar between patients groups and consistent with Canadian Cardiovascular Society Angina Grading Scale class III or IV disease, indicating moderate to severe limitation of daily activities, the team notes.

At the 6 month follow-up, patients with INOCA had a lower angina score, indicating worse disease, and a worse treatment response than those in other groups, after adjusting for between group differences and overall risk.

INOCA patients had 12% lower angina scores at follow-up versus CAD patients treated medically (p=0.181), 21% lower scores versus CAD patients given PCI (p<0.001) and 27% lower scores compared with those who underwent CABG surgery (p=0.001).

The proportion of patients who were angina-free at 6 months was also lower in the INOCA group, at 20% versus 23% for CAD patients treated medically, 50% versus CAD patients given PCI, and 55% for those who had CABG surgery (p<0.001 for trend).

The team also reports that, compared with all other groups, INOCA patients had overall reduced quality of life on the EQ5D index as well as increased psychological distress at 6 months.

Over a median follow-up of 18 months, there were 23 (6%) major adverse cardiovascular events, with no significant differences between the groups (p=0.890).

The study was funded by the British Heart Foundation.

No conflicts of interest declared.

ESC 2020: Angina, quality of life and prognosis: prospective comparison of patients undergoing invasive management. Presented 28 August. Abstract

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Angina Patients Without Obstructive CAD Have Worse Outcomes - Medscape