NONOBSTRUCTIVE CORONARY ARTERY DISEASE - CLINICAL RELEVANCE, DIAGNOSIS, MANAGEMENT AND PROPOSAL OF NEW PATHOPHYSIOLOGICAL CLASSIFICATION

Zorin Makarović, Sandra Makarović, Ines Bilić-Ćurčić, Ivan Mihaljević, Dražen Mlinarević, Zorin Makarović, Sandra Makarović, Ines Bilić-Ćurčić, Ivan Mihaljević, Dražen Mlinarević

Abstract

- New data gathered from large clinical trials indicate that nonobstructive coronary artery disease (non-CAD) is a clinical entity that should not be ignored. It is estimated that 50% of female population undergoing coronarography are diagnosed with non-CAD. There is also an increase in the prevalence of non-CAD in both genders, which is probably due to gradual expanding of clinical indications for angiography in patients with angina. Furthermore, considering the increased mortality risk established recently, a prognosis of non-CAD is not benign as previously thought. However, the concept and definition of non-CAD remains elusive causing difficulties in diagnosis and treatment. One of the major shortcomings is the exclusion-based diagnosis of non-CAD. Furthermore, treatment of non-CAD still presents a great challenge and optimal therapy is yet to be determined. There are two major hypotheses explaining the pathophysiological mechanisms of non-CAD, i.e. ischemic hypothesis based on abnormal microvascular dysfunction and non-ischemic one based on altered pain perception. This review encompasses a broader spectrum of pathophysiological mechanisms of non-CAD, and proposes a new way of classification based on the major disorder involved: type I (ischemic mechanisms) and type II (non-ischemic mechanisms), depending on which mechanism predominates. Hopefully, this would provide new insights in the understanding of this disorder, thus leading to accurate and early diagnosis and successful treatment, especially considering the increased mortality risk in these patients.

Keywords: Angiography; Classification; Coronary artery disease; Diagnosis.

Figures

Fig. 1
Fig. 1
Risk factors for development of non-CAD. There is a relationship between ischemic (endothelial and non-endothelial dependent theory) and non-ischemic (neural and habitual theory) risk factors. Repeated episodes of micro ischemia due to microvascular coronary dysfunction could lead to neural disorder affecting adrenergic or nociceptive fibers through fibrosis and mild prolonged inflammation. Habitual and neural theory could also be connected.

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