Consider intensive interventions for ‘common’ INOCA in young women
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RANCHO PALOS VERDES, Calif. — Observational studies show ischemia with no obstructive CAD is “common” among younger women, and several trials support both traditional and novel interventions to reduce risk, according to a speaker.
Women with ischemia with no obstructive CAD (INOCA) or MI without obstructive CAD (MINOCA) are at elevated risk for poor CV outcomes, and clinicians need to pinpoint the cause of ischemia, Cardiology Today Editorial Board Member C. Noel Bairey Merz, MD, FACC, FAHA, professor of medicine (cardiology) and director of the Barbra Streisand Women’s Heart Center at the Smidt Heart Institute, Cedars-Sinai, said during a presentation at the Cardiometabolic Health Congress (CMHC) Women’s Cardiometabolic Health and Wellness Masterclass.
Mechanisms for INOCA include traditional cardiac risk factors as well as novel, sex-specific risk factors; interventional trials support traditional and novel interventions, Bairey Merz said.
“If you go back to the registries with angiographic core lab data, you can see that, for women, acute coronary syndrome did not have any obstructive coronary disease one-third of the time,” Bairey Merz said during a presentation. “One in 10 of these women had no obstructive coronary disease in STEMI. We thought we knew what caused heart attacks — clogged up arteries. These data were right under our nose. If you had your male binoculars on, you always saw obstructive coronary disease. If in one out of 10 STEMIs that did not happen, it was considered an outlier. ‘Outliers’ are more like one in 1,000, not 10%.”
WISE study: A systemic approach
The Women’s Ischemia Syndrome Evaluation (WISE), a study examining symptomatic women referred for clinically indicated coronary angiography and initially followed for a mean of 5.2 years, demonstrated that women with symptoms and signs of ischemia but no significant epicardial obstructive CAD were at elevated risk for recurrent angina hospitalization, major adverse CV events, death and health resource consumption rivaling those with obstructive coronary disease.
The WISE INOCA outcomes studies underscored a critical need for further research into underlying pathophysiology, prognostic factors, diagnosis and management strategies for INOCA and coronary microvascular disease, Bairey Merz said.
“We were able to estimate that there were probably 3 million women in the United States with this coronary microvascular dysfunction,” Bairey Merz said. “This placed it as a larger problem than breast cancer in both prevalence as well as prognosis. More recently, we termed this phenomenon INOCA.”
Data published in 2009 compared WISE participants with participants in the St. James Women Take Heart Project, a study of asymptomatic women with no history of heart disease. In that analysis, 5-year annualized rates of CV events were 16% in women from WISE with nonobstructive CAD (stenosis in any coronary artery of 1% to 49%), 7.9% in women from WISE with normal coronary arteries (stenosis of 0% in all coronary arteries), and 2.4% in asymptomatic Women Take Heart participants (P .002), after adjusting for baseline CAD risk factors.
“Our young women are actually the ones in the most trouble,” Bairey Merz said. “By the time women get to be elderly, aged 65 to 75 years, they tend of behave like men. So, they get [the care] they need because they have obstructive coronary disease.”
‘Eliminate’ sex-related disparities
Translational work is ongoing to promote investigative findings into guidelines, Bairey Merz said. Bairey Merz and colleagues designed the ongoing WARRIOR study to evaluate intensive medical therapy that includes high-intensity statins and ACE inhibitor or angiotensin receptor blocker therapy — the “things that work,” according to Bairey Merz — compared with usual care in 4,422 women with angina and no obstructive coronary disease.
The primary outcome is major adverse cardiac events, defined as CV death, nonfatal MI, stroke, hospitalization for angina and hospitalization for HF. Secondary outcomes include quality of life, time to return to work, health care utilization, angina, CV death and individual primary outcome components that occur during 3 years of follow-up.
“For those of you who may feel like you are talking to the wall getting patients to take their statin, give them free study drug,” Bairey Merz said. “I have a lot of statin deniers that, once randomized to the intensive medical arm, surprisingly, they took their statin.”
The results of this trial will provide important data necessary to inform guidelines regarding how best to manage this growing and challenging population of women with INOCA, Bairey Merz said.
“That is why we are doing WARRIOR, to improve human health and eliminate sex-related disparities,” Bairey Merz said.
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Bairey Merz NC. Coronary disease in women. Presented at: CMHC Women’s Cardiometabolic Health and Wellness Masterclass; Sept. 9-11, 2022; Rancho Palos Verdes, California.
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