‘We have work to do’: Increased physician recognition needed for INOCA, MINOCA
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Key takeaways:
- Consider nonobstructive coronary disease in women and men who present with chest pain.
- More research is needed on treatment for people with atypical phenotypes of ischemic heart disease.
Patients with nonobstructive coronary artery disease often wait years for a diagnosis and experience marked decline in quality of life, according to a speaker at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease.
Symptoms of INOCA, or ischemia with no obstructive coronary arteries, and MINOCA, or myocardial infarction with no obstructive coronary arteries, are associated with adverse physical, mental and social health quality of life comparable to patients with symptoms of obstructive coronary arteries, according to Martha Gulati, MD, MS, FACC, FAHA, FASPC, associate director of the Barbra Streisand Women’s Heart Center, director of preventive cardiology at Cedars-Sinai and president of the American Society of Preventive Cardiology. Functional capacity declines are evident after the onset of INOCA symptoms, and increased patient awareness, physician recognition and diagnosis and clinical trials are needed to develop evidence-based guidelines for what is becoming an increasingly recognized CV disorder.
“When I was in medical school, I remember this figure that said you could not have an abnormal stress test until there was an obstructive lesion,” Gulati said during a presentation. “Only then were things ‘abnormal.’ The common remark was, ‘Good news, it wasn’t a heart attack after all, you had normal coronary arteries.’ We never gave an answer to the patient about what was actually going on. Why did they have evidence of ischemia? Why did they have myocardial damage?
“Obstructive coronary disease is simply one phenotype of ischemic heart disease,” Gulati said. “Increasingly, understanding that has really changed our perspective, even when we do not find obstructive lesions.”
Looking beyond lesions
INOCA is estimated to affect at least 3 million to 4 million women and men in the United States, with significant associated health care costs, Gulati said.
“Because, often, these patients are not medically managed by many physicians or maybe they do not send them on for referral, we know these patients are rehospitalized again and again,” Gulati said. “They also undergo repeat testing because, often, they are presenting with chest pain, chest discomfort or an equivalent and already have documented ischemia.”
Registry data show INOCA is more common for women vs. men, for those with stable ischemic disease and for those with acute coronary syndrome.
“There do not seem to be significant racial differences, but the important thing to remember is that women [with nonobstructive coronaries] have worse outcomes,” Gulati said.
When there is no clear diagnosis, Gulati said coronary function testing and cardiac imaging can be valuable.
“When you see someone with nonobstructive coronary disease, I would encourage you to at least do some further testing, whether it is noninvasive imaging or coronary function testing,” Gulati said. “We know that coronary function testing is still limited, but [access] is rapidly growing across our country.”
Similarly, MINOCA, while not as severe as a “true” myocardial infarction with an obstructive lesion, is not a benign condition, Gulati said. Clinicians should similarly evaluate these patients with coronary function testing or imaging when possible, ruling out conditions such as Takotsubo syndrome or myocarditis.
“It may be that there is coronary microvascular dysfunction, but there may also be plaque rupture or plaque erosion, in situ thrombosis, spontaneous coronary artery dissection or vasospasm,” Gulati said. “We want to rule out nonischemic causes such as stress cardiomyopathy, myocarditis or any other myopathy.”
Living with INOCA, MINOCA
Living with INOCA or MINOCA has been shown to have far-reaching impacts, affecting a person’s employment, home life, social life and mental health, Gulati said.
“This is because unlike obstructive coronary disease where their quality of life improves 3 months after a myocardial infarction — almost returning to normal — it does not go back to normal after they are diagnosed with INOCA,” Gulati said. “Their functional capacity is dramatically reduced after a diagnosis of INOCA.”
In a patient self-report quality of life survey conducted by Gulati and colleagues of 1,579 members of an INOCA international patient support group, researchers found that most patients waited 3 to 10 years to receive an INOCA diagnosis; another 10% of women waited more than 10 years to receive a diagnosis. Three out of four respondents were told their symptoms were “not cardiac-related,” whereas two-thirds of respondents reported that when they presented they were discharged from the ED without any treatment.
“One in four told us they were simply prescribed an antidepressant for their symptoms, and one in three were referred to a psychiatrist and one in two were told their symptoms were due to GERD,” Gulati said. “This is how women were receiving this message, and it was predominantly women. Many of them had multiple consultations, seeing three or more cardiologists before receiving a diagnosis.”
People who reported experiencing a reduction in functional capacity also reported greater impacts to their physical and mental health, Gulati said, as well as a greater impact on work and disability.
“We have work to do with these patients,” Gulati said. “The functional capacity declines should be a warning sign that they are not living life normally and those are people you would consider for further testing and more aggressive medical management.”