Consequences of open artery ischemia underappreciated
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LOUISVILLE, Ky. — The medical community needs to understand that uncontrolled open artery ischemia is not benign, a speaker said during the American Society for Preventive Cardiology Congress on CVD Prevention.
“We have focused on the obstructive lesions for over 50 years, and now what we are beginning to recognize that arteries without obstruction still can convey some obstruction to blood flow, cause ischemia and cause adverse events,” Cardiology Today Chief Medical Editor Carl J. Pepine, MD, MACC, emeritus professor of medicine at the University of Florida, told Healio. “It is particularly a problem in women.”
A European consensus document estimates that open artery ischemia — angina with no obstructed coronary arteries (ANOCA), ischemia with no obstructive coronary arteries (INOCA) and MI with nonobstructive coronary arteries (MINOCA) — affects approximately 112 million people worldwide, Pepine said.
“The American College of Cardiology and its National Cath Lab Database have estimated that 60% to 70% of the patients who were getting coronary angiography for chest pain did not have an obstructive lesion,” Pepine told Healio. “We did the same type of analysis working with the WISE program and came to the same conclusion.”
It is not clear why women are more likely to have open artery ischemia than men, Pepine said. “The initial publications we made with the WISE program about 20 years ago, which have been replicated, showed that it is a real problem and it accounts for a large economic and societal burden,” he said. “It also consumes tremendous resources, in addition to the death and disability that it causes for the patients.”
Women with open artery ischemia tend to be younger and have more comorbidities than women with obstructive CAD, “but other than that, their symptoms are similar,” Pepine told Healio.
Coronary functional testing, which enables cardiologists to identify patients with open artery ischemia, received a class IIa recommendation in the ACC/American Heart Association Guideline for the Evaluation and Diagnosis of Chest Pain and the European Society of Cardiology guidelines on angina, Pepine said.
Among the findings from WISE were that women with coronary flow reserve less than 2.32 were more likely to experience death, MI, HF hospitalization or stroke at 5 years than women with coronary flow reserve of 2.32 or greater, Pepine said during the presentation.
There are no consensus therapies for treatment of open artery ischemia, because trials to date have been small and the population is heterogenous, he said.
“What it’s looking like is there are many targets for small-molecule therapy that can influence this syndrome,” Pepine told Healio. “There is no strong industry support for this. In the WARRIOR trial of 4,000 women, we are using intensive medical therapy that consists of a potent statin, an ACE inhibitor or angiotensin receptor blocker and aspirin vs. the usual care. A group in Scotland has a trial underway of about 350 patients called PRIZE looking at zibotentan (AstraZeneca), an endothelin receptor blocker. To the best of my knowledge, those are the only two trials of any size that are ongoing.”
Given lack of clear guidance on treatment, preventive strategies are very important for this patient population, Pepine said during the presentation.
“In the spectrum of CAD, most subsequent CV events occur in patients with nonobstructive lesions. This is important because conventional functional diagnostic strategies identify left ventricular contractility or perfusion abnormalities and are unable to detect nonobstructive CAD, and because most adverse events occur in patients with no detectable myocardial ischemia,” he said. “Accordingly, clear treatment recommendations for patients with nonobstructive CAD detected by coronary CT angiography may provide substantial benefit in terms of overall CV prevention.”
References:
- Pepine CJ, et al. J Am Coll Cardiol. 2010;doi:10.1016/j.jacc.2010.01.054.
- Sedlak T, et al. J Am Heart Assoc. 2020;doi:10.1161/JAHA.119.013234.
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Pepine CJ. Session 4: Nanette Wenger Award & Lecture. Presented at: American Society for Preventive Cardiology Congress on CVD Prevention; July 29-31, 2022; Louisville, Kentucky.
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