Management of INOCA: personalised medicine approach
Up to half of patients undergoing elective coronary angiography for chest pain do not possess obstructive coronary artery disease. Due to a lack of investigation into the potentially ischaemic basis of their condition, these patients’ symptoms are often dismissed and access to pain-alleviating treatment is denied. This type of ischaemic pain without obstructive coronary artery disease is known as ischemia with non-obstructive coronary arteries (INOCA).
This comprehensive review by Beltrame JF, Tavella R, Jones D, et al. seeks to bridge the knowledge gaps surrounding INOCA’s diagnosis and management. This includes why, who, how and when to treat INOCA, as well as potential treatments which are currently underway.
Patients with INOCA have an impaired health status with an increased risk of major adverse cardiac events (MACE). To establish a diagnosis of INOCA, non-cardiac and non-ischaemic causes must first be excluded. Functional angiography must be used to assess for coronary macrovascular or microvascular dysfunction.
Clinicians must prioritise two distinct targets for the management of INOCA: reducing both MACE risk (prognostic target) and angina symptoms (health status target). The former can be achieved through the use of cardioprotective treatments, while the latter is assured using anti-anginal therapy (anti-ischaemic and anti-nociceptive treatments).
Cardioprotective treatments refer to Calcium channel blockers for vasospastic angina, and guideline-recommended statins and angiotensin converting enzyme inhibitors for coronary microvascular disorders. Pharmacologic anti-ischaemic treatments include ivabradine, nicorandil, ranolazine, perhexiline, and trimetazidine, which are often used in combination. Treatments designed for INOCA should be personalised for each patient according to these recommendations.
Treatment of INOCA should be initiated at initial diagnosis using cardioprotective treatments, as well as anti-anginal treatments if symptoms are disabling. Clinical monitoring is a central part of INOCA management.
Emerging treatments for INOCA include intense statin/angiotensin converting enzyme inhibitors, ticagrelor and zibotentan. Novel emerging treatments initiatives further involve CD34 stem cells, coronary sinus reducer, and Rhodiola rosea capsules.