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      An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group

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          This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.

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          Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease.

          The diagnosis of coronary-artery disease has become increasingly complex. Many different results, obtained from tests with substantial imperfections, must be integrated into a diagnostic conclusion about the probability of disease in a given patient. To approach this problem in a practical manner, we reviewed the literature to estimate the pretest likelihood of disease (defined by age, sex and symptoms) and the sensitivity and specificity of four diagnostic tests: stress electrocardiography, cardiokymography, thallium scintigraphy and cardiac fluoroscopy. With this information, test results can be analyzed by use of Bayes' theorem of conditional probability. This approach has several advantages. It pools the diagnostic experience of many physicians ans integrates fundamental pretest clinical descriptors with many varying test results to summarize reproducibly and meaningfully the probability of angiographic coronary-artery disease. This approach also aids, but does not replace, the physician's judgment and may assit in decisions on cost effectiveness of tests.
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            Ischemia and No Obstructive Coronary Artery Disease (INOCA): Developing Evidence-Based Therapies and Research Agenda for the Next Decade.

            The Cardiovascular Disease in Women Committee of the American College of Cardiology, in conjunction with interested parties (from the National Heart, Lung, and Blood Institute, American Heart Association, and European Society of Cardiology), convened a working group to develop a consensus on the syndrome of myocardial ischemia with no obstructive coronary arteries. In general, these patients have elevated risk for a cardiovascular event (including acute coronary syndrome, heart failure hospitalization, stroke, and repeat cardiovascular procedures) compared with reference subjects and appear to be at higher risk for development of heart failure with preserved ejection fraction. A subgroup of these patients also has coronary microvascular dysfunction and evidence of inflammation. This document provides a summary of findings and recommendations for the development of an integrated approach for identifying and managing patients with ischemia with no obstructive coronary arteries and outlines knowledge gaps in the area. Working group members critically reviewed available literature and current practices for risk assessment and state-of-the-science techniques in multiple areas, with a focus on next steps needed to develop evidence-based therapies. This report presents highlights of this working group review and a summary of suggested research directions to advance this field in the next decade.
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              Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events.

              Patients with chest pain and no obstructive coronary artery disease (CAD) are considered at low risk for cardiovascular events but evidence supporting this is scarce. We investigated the prognostic implications of stable angina pectoris in relation to the presence and degree of CAD with no obstructive CAD in focus. We identified 11 223 patients referred for coronary angiography (CAG) in 1998-2009 with stable angina pectoris as indication and 5705 participants from the Copenhagen City Heart Study for comparison. Main outcome measures were major adverse cardiovascular events (MACE), defined as cardiovascular death, myocardial infarction, stroke or heart failure, and all-cause mortality. Significantly more women (65%) than men (32%) had no obstructive CAD (P< 0.001). In Cox's models adjusted for age, body mass index, diabetes, smoking, and use of lipid-lowering or antihypertensive medication, hazard ratios (HRs) associated with no obstructive CAD were similar in men and women. In the pooled analysis, the risk of MACE increased with increasing degrees of CAD with multivariable-adjusted HRs of 1.52 (95% confidence interval, 1.27-1.83) for patients with normal coronary arteries and 1.85 (1.51-2.28) for patients with diffuse non-obstructive CAD compared with the reference population. For all-cause mortality, normal coronary arteries and diffuse non-obstructive CAD were associated with HRs of 1.29 (1.07-1.56) and 1.52 (1.24-1.88), respectively. Patients with stable angina and normal coronary arteries or diffuse non-obstructive CAD have elevated risks of MACE and all-cause mortality compared with a reference population without ischaemic heart disease.

                Author and article information

                European Heart Journal
                Oxford University Press (OUP)
                July 06 2020
                July 06 2020
                [1 ]Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, M4:146 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
                [2 ]IRCCS San Raffaele Scientific Institute, Milan, Italy
                [3 ]Vita Salute University and San Raffaele Hospital, Milan, Italy
                [4 ]British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
                [5 ]Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
                [6 ]Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
                [7 ]Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
                [8 ]European Hospital Georges Pompidou (Cardiology Department), Paris University and Paris Cardiovascular Research Center (INSERMU970), Paris, France
                [9 ]Department of Cardiology, Amsterdam UMC, Location VU University Medical Center, Amsterdam, the Netherlands
                [10 ]Department of Cardiac, Thoracic and Vascular Science and Public Health, Padova, Italy
                [11 ]North Cumbria Integrated Care NHS Foundation Trust, Cumbria, UK
                [12 ]Department of Cardiology, Lariboisière Hospital Paris University, Paris, France
                [13 ]National Heart and Lung Institute, Imperial College London, London, UK
                [14 ]Ludwig-Maximilians-University, Munich, Germany
                [15 ]Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
                [16 ]Bart’s Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, UK
                [17 ]Lifespan Cardiovascular Institute and Warren Alpert Medical School of Brown University, Providence, RI, USA
                [18 ]Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, CiberCV, Barcelona, Spain
                [19 ]Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
                [20 ]Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
                [21 ]CardioThoracic-Vascular and Transplant Department, A.O.U. ‘Policlinico-Vittorio Emanuele’, University of Catania, Catania, Italy
                [22 ]Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
                [23 ]Yale University School of Medicine, New Haven, CT, USA
                © 2020




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