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

Abstract

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.

Conflict of interest statement

Vijay Kunadian reports other from Bayer, other from Amgen, other from Abbott, other from Astra Zeneca, other from Daiichi Sankyo, outside the submitted work; and Vijay Kunadian is supported by an external research grant from Astra Zeneca (funder reference number ISSBRIL0303). Vijay Kunadian is also supported/funded by the National Institute for Health Research Newcastle Biomedical Research Centre based at Newcastle Hospitals NHS Foundation Trust and Newcastle University. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Vijay Kunadian also supported by the British Heart Foundation Clinical Study Grant CS/15/7/31679 for the British Heart Foundation older patients with non-ST SEgmeNt elevatIOn myocaRdial infarction Randomised Interventional TreAtment Trial. Alaide Chieffo reports personal fees from Abiomed, personal fees from Biosensor, personal fees from Abbott, personal fees from Cardinal Health, personal fees from Magenta, outside the submitted work. Paolo G. Camici reports personal fees from Servier, during the conduct of the study. Colin Berry reports grants, non-financial support and other from Abbott Vascular, grants, non-financial support and other from AstraZeneca, non-financial support from Boehringer Ingelheim, grants and non-financial support from GSK, grants, non-financial support and other from HeartFlow, non-financial support and other from Opsens, grants, non-financial support and other from Novartis, non-financial support from Siemens Healthcare, outside the submitted work; and Colin Berry acknowledges research support from the British Heart Foundation (PG/17/ 2532884; FS/17/26/32744; RE/18/6134217) and Medical Research Council (MR/S005714/1). Javier Escaned reports personal fees from Abbott, personal fees from Philips, outside the submitted work. Angela H.E.M. Maas has nothing to disclose. Eva Prescott has nothing to disclose. Nicole Karam has nothing to disclose. Yolande Appelman has nothing to disclose. Chiara Fraccaro has nothing to disclose. Gill Louise Buchanan reports grants and personal fees from Bayer, grants and personal fees from Pfizer, grants and personal fees from Daichii-Sanyo, grants from Menarini, outside the submitted work. Stephane Manzo-Silberman has nothing to disclose. Rasha Al-Lamee reports other from Philips Volcano, other from Menarini, outside the submitted work. Evelyn Regar has nothing to dis-close. Alexandra Lansky has nothing to disclose. J. Dawn Abbott has nothing to disclose. Lina Badimon reports grants from AstraZeneca, other from Sanofi, grants from A-Biotics, other from Lilly, other from Astra-Zeneca, other from Research Forum on Beer and Lyfestyle, other from Research Forum on Beer and Lyfestyle, other from Pfizer, outside the submitted work. Dirk J. Duncker reports grants from Dutch Heart Foundation, outside the submitted work. Roxana Mehran reports grants from Abbott Laboratories, grants from AstraZeneca, grants from Bayer, grants from Beth Israel Deaconess, grants from BMS, grants from CSL Behring, grants from DSI, grants from Medtronic, grants from Novartis Pharmaceuticals, grants from OrbusNeich, personal fees from Abbott Laboratories, other from Abbott Laboratories, other from Abiomed, other from The Medicines Company, personal fees from Boston Scientific, personal fees from Medscape/WebMD, personal fees from Siemens Medical Solutions, personal fees from PLx Opco Inc/dba PLx Pharma Inc, non-financial support and other from Regeneron Pharmaceuticals, personal fees from Roivant Sciences, other from Spectranetics/Philips/Volcano Corp, personal fees from Sanofi, personal fees from Medtelligence (Janssen Scientific Affairs), personal fees from Janssen Scientific Affairs, other from Bristol Myers Squibb, other from Watermark Research Partners, other from Claret Medical, other from Elixir Medical, outside the submitted work. Davide Capodanno has nothing to disclose. Andreas Baumbach has nothing to disclose.

Figures

Visual summary.

Figure 1.

Mechanisms of myocardial ischaemia.

Figure 2.

Mechanisms of myocardial ischaemia in INOCA and obstructive coronary artery disease. CAD: coronary artery disease; FFR: fractional flow reserve.

Figure 3.

Non-invasive evaluation of INOCA. GP: general practitioner

Figure 4.

Invasive evaluation of INOCA. CFR: coronary flow reserve; FCA: functional coronary angiography; FFR: fractional flow reserve; IMR: index of microvascular resistance; LVEDP: left ventricular end-diastolic pressure. aAnd negative non-invasive or invasive testing for epicardial ischaemia. bCombo wire is an alternative option to measure FFR, CFR and IMR.

Figure 5.

Management of INOCA. ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker.

Figure 6.

Key messages.