Angina: contemporary diagnosis and management

Thomas Joseph Ford, Colin Berry, Thomas Joseph Ford, Colin Berry

No abstract available

Keywords: cardiac catheterization and angiography; chronic coronary disease; coronary artery disease; percutaneous coronary intervention.

Conflict of interest statement

Competing interests: CB is employed by the University of Glasgow which holds consultancy and research agreements with companies that have commercial interests in the diagnosis and treatment of angina (Abbott Vascular, AstraZeneca, Boehringer Ingelheim, GSK, Menarini, Opsens, Philips and Siemens Healthcare.)

Figures

Figure 1
Figure 1
Reappraisal of ischaemic heart disease pathophysiology. Distinct functional and structural mechanisms can affect coronary vascular function and frequently coexist leading to myocardial ischaemia. CAD, coronary artery disease.
Figure 2
Figure 2
Contributing factors to myocardial ischaemia. The contributors to the physiological myocardial perfusion gradient and resultant ischaemia can be broken down at patient-level into systemic, cardiac and coronary factors. CAD, coronary artery disease; SEVR, subendocardial viability ratio..
Figure 3
Figure 3
Empirical pharmacological treatments for patients with angina. ACEi, Angiotensin converting enzyme inhibitor; ASP, aspirin; BB, beta-blocker; Endo, endothelial; IVA, ivabradine; MVA, microvascular angina; NIC, nicorandil; NIT, nitrate; Obs CAD, obstructive coronary artery disease;, RAN, ranolazine; RF, risk factor.

References

    1. Wang H, Naghavi M, Allen C, et al. . Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the global burden of disease study 2015. Lancet 2016;388:1459–544.10.1016/S0140-6736(16)31012-1
    1. Cardiovascular Disease Statistics 2018. London: British Heart Foundation, 2018.
    1. Kligfield P. The early pathophysiolic understanding of angina pectoris (Edward Jenner, Caleb Hillier Parry, Alan burns). Am J Cardiol 1982;50:1433–5.10.1016/0002-9149(82)90487-8
    1. Cine-coronary arteriography Circulation. 227 East Washington Square, Philadelphia, PA 19106.: Lippincott Williams and Wilkins, 1959.
    1. Kaski J-C, Crea F, Gersh BJ, et al. . Reappraisal of ischemic heart disease. Circulation 2018;138:1463–80.10.1161/CIRCULATIONAHA.118.031373
    1. Knuuti J, Wijns W, Saraste A, et al. . ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2019;2019.
    1. Montalescot G, Sechtem U, Achenbach S, et al. . 2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European Society of cardiology. Eur Heart J 2013;34:2949–3003.10.1093/eurheartj/eht296
    1. Ford TJ, Corcoran D, Berry C. Stable coronary syndromes: pathophysiology, diagnostic advances and therapeutic need. Heart 2018;104:284–92.10.1136/heartjnl-2017-311446
    1. Patel MR, Peterson ED, Dai D, et al. . Low diagnostic yield of elective coronary angiography. N Engl J Med 2010;362:886–95.10.1056/NEJMoa0907272
    1. Arnold SV, Grodzinsky A, Gosch KL, et al. . Predictors of physician under-recognition of angina in outpatients with stable coronary artery disease. Circulation 2016;9:554–9.10.1161/CIRCOUTCOMES.116.002781
    1. Lee JM, Choi KH, Park J, et al. . Physiological and clinical assessment of resting physiological indexes. Circulation 2019;139:889–900.10.1161/CIRCULATIONAHA.118.037021
    1. Gould KL. Dynamic coronary stenosis. Am J Cardiol 1980;45:286–92.10.1016/0002-9149(80)90647-5
    1. Asrress KN, Williams R, Lockie T, et al. . Physiology of angina and its alleviation with nitroglycerin: insights from invasive catheter laboratory measurements during exercise. Circulation 2017;136:24–34.10.1161/CIRCULATIONAHA.116.025856
    1. Garber CE, Carleton RA, Camaione DN, et al. . The threshold for myocardial ischemia varies in patients with coronary artery disease depending on the exercise protocol. J Am Coll Cardiol 1991;17:1256–62.10.1016/S0735-1097(10)80132-9
    1. Steg PG, Greenlaw N, Tendera M, et al. . Prevalence of anginal symptoms and myocardial ischemia and their effect on clinical outcomes in outpatients with stable coronary artery disease: data from the International observational clarify registry. JAMA Intern Med 2014;174:1651–9.10.1001/jamainternmed.2014.3773
    1. Gould KL, Johnson NP, Nitroglycerine JNP. Nitroglycerine and angina: evolving clinical coronary physiology beyond fractional flow reserve and coronary flow reserve. Circulation 2017;136:35–8.10.1161/CIRCULATIONAHA.117.028791
    1. Ong P, Camici PG, Beltrame JF, et al. . International standardization of diagnostic criteria for microvascular angina. Int J Cardiol 2018;250:16–20.10.1016/j.ijcard.2017.08.068
    1. Sara JDS, Corban MT, Prasad M, et al. . The prevalence of myocardial bridging associated with coronary endothelial dysfunction in patients with chest pain and non-obstructive coronary artery disease. EuroIntervention 2019. doi:10.4244/EIJ-D-18-00920. [Epub ahead of print: 15 Jan 2019].
    1. Ford TJ, Rocchiccioli P, Good R, et al. . Systemic microvascular dysfunction in microvascular and vasospastic angina. Eur Heart J 2018;39:4086–97.10.1093/eurheartj/ehy529
    1. Maddox TM, Stanislawski MA, Grunwald GK, et al. . Nonobstructive coronary artery disease and risk of myocardial infarction. JAMA 2014;312:1754–63.10.1001/jama.2014.14681
    1. Tavella R, Cutri N, Tucker G, et al. . Natural history of patients with insignificant coronary artery disease. Eur Heart J Qual Care Clin Outcomes 2016;2:117–24.10.1093/ehjqcco/qcv034
    1. Raphael CE, Cooper R, Parker KH, et al. . Mechanisms of myocardial ischemia in hypertrophic cardiomyopathy: insights from wave intensity analysis and magnetic resonance. J Am Coll Cardiol 2016;68:1651–60.10.1016/j.jacc.2016.07.751
    1. Gould KL, Johnson NP. Imaging coronary blood flow in as: let the data talk, again. J Am Coll Cardiol 2016;67:1423–6.10.1016/j.jacc.2016.01.053
    1. Pasceri V, Lanza GA, Buffon A, et al. . Role of abnormal pain sensitivity and behavioral factors in determining chest pain in syndrome X. J Am Coll Cardiol 1998;31:62–6.10.1016/S0735-1097(97)00421-X
    1. Olson MB, Kelsey SF, Matthews K, et al. . Symptoms, myocardial ischaemia and quality of life in women: results from the NHLBI-sponsored wise study. Eur Heart J 2003;24:1506–14.10.1016/S0195-668X(03)00279-3
    1. Ford TJ, Stanley B, Good R, et al. . Stratified medical therapy using invasive coronary function testing in angina. J Am Coll Cardiol 2018;72:2841–55.10.1016/j.jacc.2018.09.006
    1. Ct coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. The Lancet 2015;385:2383–91.10.1016/S0140-6736(15)60291-4
    1. Hemingway H, Langenberg C, Damant J, et al. . Prevalence of angina in women versus men: a systematic review and meta-analysis of international variations across 31 countries. Circulation 2008;117:1526–36.10.1161/CIRCULATIONAHA.107.720953
    1. Kreatsoulas C, Shannon HS, Giacomini M, et al. . Reconstructing angina: cardiac symptoms are the same in women and men. JAMA Intern Med 2013;173:829–31.10.1001/jamainternmed.2013.229
    1. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350–8.10.1056/NEJM197906143002402
    1. Bittencourt MS, Hulten E, Polonsky TS, et al. . European Society of Cardiology–Recommended coronary artery disease Consortium pretest probability scores more accurately predict obstructive coronary disease and cardiovascular events than the diamond and Forrester score. Circulation 2016;134:201–11.10.1161/CIRCULATIONAHA.116.023396
    1. (NICE) NIfHaCE Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin (update). CG95. London: National Institute for Health and Clinical Excellence, 2016.
    1. Douglas PS, Hoffmann U, Patel MR, et al. . Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med 2015;372:1291–300.10.1056/NEJMoa1415516
    1. Williams MC, Hunter A, Shah A, et al. . Symptoms and quality of life in patients with suspected angina undergoing CT coronary angiography: a randomised controlled trial. Heart 2017;103:995–1001.10.1136/heartjnl-2016-310129
    1. Min JK, Leipsic J, Pencina MJ, et al. . Diagnostic accuracy of fractional flow reserve from anatomic CT angiography. JAMA 2012;308:1237–45.10.1001/2012.jama.11274
    1. Nicol EPS, Roditi G, Roobottom C, British Society of cardiovascular Imaging/ British Society of cardiovascular computed tomography . The challenge of national CT coronary angiography (CTCA) provision in response to NICE CG95 update 2016. London: British Society of Cardiovascular Imaging, 2016.
    1. Richards T, Coulter A, Wicks P. Time to deliver patient centred care. BMJ 2015;350:h53010.1136/bmj.h530
    1. Corcoran D, Ford TJ, Hsu L-Y, et al. . Rationale and design of the coronary microvascular angina cardiac magnetic resonance imaging (CorCMR) diagnostic study: the CorMicA CMR sub-study. Open Heart 2018;5:e00092410.1136/openhrt-2018-000924
    1. Danad I, Szymonifka J, Twisk JWR, et al. . Diagnostic performance of cardiac imaging methods to diagnose ischaemia-causing coronary artery disease when directly compared with fractional flow reserve as a reference standard: a meta-analysis. Eur Heart J 2017;38:991–8.10.1093/eurheartj/ehw095
    1. Taqueti VR, Shaw LJ, Cook NR, et al. . Excess cardiovascular risk in women relative to men referred for coronary angiography is associated with severely impaired coronary flow reserve, not obstructive disease. Circulation 2017;135:566–77.10.1161/CIRCULATIONAHA.116.023266
    1. Gould KL, Johnson NP. Coronary physiology beyond coronary flow reserve in microvascular angina: JACC state-of-the-art review. J Am Coll Cardiol 2018;72:2642–62.10.1016/j.jacc.2018.07.106
    1. Beltrame JF, Crea F, Kaski JC, et al. . International standardization of diagnostic criteria for vasospastic angina. Eur Heart J 2017;38:2565–8.10.1093/eurheartj/ehv351
    1. Rahman H, Corcoran D, Aetesam-ur-Rahman M, et al. . Diagnosis of patients with angina and non-obstructive coronary disease in the catheter laboratory. Heart 2019;105:1536–42.10.1136/heartjnl-2019-315042
    1. Lee JM, Jung J-H, Hwang D, et al. . Coronary flow reserve and microcirculatory resistance in patients with intermediate coronary stenosis. J Am Coll Cardiol 2016;67:1158–69.10.1016/j.jacc.2015.12.053
    1. Taqueti VR, Hachamovitch R, Murthy VL, et al. . Global coronary flow reserve is associated with adverse cardiovascular events independently of luminal angiographic severity and modifies the effect of early revascularization. Circulation 2015;131:19–27.10.1161/CIRCULATIONAHA.114.011939
    1. Sezer M, Kocaaga M, Aslanger E, et al. . Bimodal pattern of coronary microvascular involvement in diabetes mellitus. J Am Heart Assoc 2016;510.1161/JAHA.116.003995
    1. Ford TJ, Berry C, B . How to diagnose and manage angina without obstructive coronary artery disease: lessons from the British heart Foundation CorMicA trial. Interv Cardiol 2019;14:76–82.10.15420/icr.2019.04.R1
    1. Ford TJ, Stanley B, Sidik N, et al. . One-year outcomes of angina management guided by invasive coronary function testing (CorMicA). JACC Cardiovasc Interv 2019;4788.
    1. Lewin RJ, Furze G, Robinson J, et al. . A randomised controlled trial of a self-management plan for patients with newly diagnosed angina. Br J Gen Pract 2002;52:194-6–9.
    1. Bairey Merz CN, Handberg EM, Shufelt CL, et al. . A randomized, placebo-controlled trial of late Na current inhibition (ranolazine) in coronary microvascular dysfunction (CMD): impact on angina and myocardial perfusion reserve. Eur Heart J 2016;37:1504–13.10.1093/eurheartj/ehv647
    1. Crea F, Lanza GA. Treatment of microvascular angina: the need for precision medicine. Eur Heart J 2016;37:1514–6.10.1093/eurheartj/ehw021
    1. Beltrame JF, Horowitz JD. Why do nitrates have limited efficacy in coronary microvessels?: Editorial to: "Lack of nitrates on exercise stress test results in patients with microvascular angina" by G. Russo et al. Cardiovasc Drugs Ther 2013;27:187–8.10.1007/s10557-013-6454-0
    1. Oelze M, Knorr M, Kröller-Schön S, et al. . Chronic therapy with isosorbide-5-mononitrate causes endothelial dysfunction, oxidative stress, and a marked increase in vascular endothelin-1 expression. Eur Heart J 2013;34:3206–16.10.1093/eurheartj/ehs100
    1. Mohri M, Koyanagi M, Egashira K, et al. . Angina pectoris caused by coronary microvascular spasm. Lancet 1998;351:1165–9.10.1016/S0140-6736(97)07329-7
    1. Fearon WF, Okada K, Kobashigawa JA, et al. . Angiotensin-converting enzyme inhibition early after heart transplantation. J Am Coll Cardiol 2017;69:2832–41.10.1016/j.jacc.2017.03.598
    1. Marinescu MA, Löffler AI, Ouellette M, et al. . Coronary microvascular dysfunction, microvascular angina, and treatment strategies. JACC Cardiovasc Imaging 2015;8:210–20.10.1016/j.jcmg.2014.12.008
    1. Nishigaki K, Inoue Y, Yamanouchi Y, et al. . Prognostic effects of calcium channel blockers in patients with vasospastic angina–a meta-analysis. Circ J 2010;74:1943–50.10.1253/circj.CJ-10-0292
    1. Takahashi J, Nihei T, Takagi Y, et al. . Prognostic impact of chronic nitrate therapy in patients with vasospastic angina: multicentre registry study of the Japanese coronary spasm association. Eur Heart J 2015;36:228–37.10.1093/eurheartj/ehu313
    1. (NICE) NIfHaCE Stable angina: management. NICE Guideline [CG126]. London: NICE, 2011, Updated 2016.
    1. Weisz G, Généreux P, Iñiguez A, et al. . Ranolazine in patients with incomplete revascularisation after percutaneous coronary intervention (RIVER-PCI): a multicentre, randomised, double-blind, placebo-controlled trial. The Lancet 2016;387:136–45.10.1016/S0140-6736(15)00459-6
    1. Sainsbury PA, Fisher M, de Silva R. Alternative interventions for refractory angina. Heart 2017;103:1911–22.10.1136/heartjnl-2015-308564
    1. Henry TD, Satran D, Jolicoeur EM. Treatment of refractory angina in patients not suitable for revascularization. Nat Rev Cardiol 2014;11:78–95.10.1038/nrcardio.2013.200

Source: PubMed

Sponzoři a spolupracovníci

Zdravotní podmínky

Drogové intervence

3
Předplatit