Adverse prognosis in women with angina and no obstructive CAD
0ver 90% of angina patients referred for assessment and over 2/3 of patients undergoing invasive coronary angiography (CAG) do not have obstructive coronary artery disease (CAD). A specific acronym ANOCA (angina with no obstructive CAD) has been coined to describe this feature. ANOCA is predominantly seen in women who, like all patients with ANOCA are at increased risk of major adverse cardiovascular events compared with asymptomatic patients (1).
In patients with Angina, coronary microvascular dysfunction (CMD) is now considered a possible cause of symptoms and a marker of poor prognosis. Several diagnostic test solutions are available to evaluate CMD in view of risk stratification.
One of them is transthoracic Doppler echocardiography (TTDE) coronary flow velocity reserve (CFVR) that has been shown to be a consistent outcome predictor in angina patients at large.
The aim of the iPOWER (Improving Diagnosis and Treatment of Women with Angina Pectoris and Microvascular Disease) is an investigator-initiated prospective cohort
study and its objective was to determine whether routine assessment of CFVR is feasible and identifies women with increased risk of major adverse cardiovascular events in a large homogeneous patient cohort of women with angina and no obstructive CAD (2).The authors included 1853 women with angina and no obstructive CAD on angiogram who were free of previous CAD, heart failure, or valvular heart disease. Coronary microvascular dysfunction was assessed by Doppler echocardiography in the left anterior descending artery as coronary flow velocity reserve (CFVR). They found that CFVR is an independent predictor of a composite outcome of CVD death, MI, heart failure, stroke, and coronary revascularization in women with angina pectoris and no obstructive CAD.
Take home message: assessment of CFVR by echocardiography is feasible and is predictive of adverse outcome in women with angina and no obstructive CAD. Results support a more aggressive preventive management of these patients and more research is needed.