Ischemia and no obstructive coronary arteries (INOCA): A narrative review

Elsevier

Available online 12 November 2022

AtherosclerosisHighlights•

Myocardial ischemia and no obstructive coronary arteries (INOCA) is a chronic coronary syndrome that predominates in women and is associated with adverse cardiovascular mortality and outcomes, including myocardial infarction and heart failure with preserved ejection fraction (HFpEF).

INOCA occurs in both men and women and portends an adverse prognosis in both sexes; however, women are more impacted by angina, with recurrent hospitalizations, and report a lower quality of life compared to men with INOCA.

In addition to diffuse coronary plaque and epicardial coronary endothelial dysfunction that are prevalent in INOCA, coronary microvascular dysfunction (CMD) is implicated as a key contributor to microvascular ischemia and symptoms in this INOCA. Epicardial vasospasm can also coexist with normal coronary arteries that have no visible plaque on intravascular imaging.

In the setting of risk factors that lead to oxidative stress and inflammation, CMD occurs due to structural and/or functional causes, resulting in impaired blood flow supply to match myocardial demand.

While non-invasive stress testing modalities detect abnormal flow reserve, invasive coronary function testing is needed to assess abnormal coronary vasoreactivity (epicardial and microcirculatory dysfunction) as well as vasospasm.

In addition to pharmacologic anti-anginal and anti-ischemic strategies, non-pharmacologic treatments are used to manage INOCA, while large, outcomes-based trials are ongoing.

Abstract

Myocardial ischemia with no obstructive coronary arteries (INOCA) is a chronic coronary syndrome condition that is increasingly being recognized as a substantial contributor to adverse cardiovascular mortality and outcomes, including myocardial infarction and heart failure with preserved ejection fraction (HFpEF). While INOCA occurs in both women and men, women are more likely to have the finding of INOCA and are more adversely impacted by angina, with recurrent hospitalizations and a lower quality of life with this condition. Abnormal epicardial coronary vascular function and coronary microvascular dysfunction (CMD) have been identified in a majority of INOCA patients on invasive coronary function testing. CMD can co-exist with obstructive epicardial CAD, diffuse non-obstructive epicardial CAD, and with coronary vasospasm. Epicardial vasospasm can also occur with normal coronary arteries that have no atherosclerotic plaque on intravascular imaging. While all predisposing factors are not clearly understood, cardiometabolic risk factors, and endothelium dependent and independent mechanisms that increase oxidative stress and inflammation are associated with microvascular injury, CMD and INOCA. Cardiac autonomic dysfunction has also been implicated in abnormal vasoreactivity and persistent symptoms. INOCA is under-recognized and under-diagnosed, partly due to the heterogenous patient populations and mechanisms. However, diagnostic testing methods are available to guide INOCA management. Treatment of INOCA is evolving, and focuses on cardiac risk factor control, improving ischemia, reducing atherosclerosis progression, and improving angina and quality of life. This review focuses on INOCA, relations to HFpEF, available diagnostics, current and investigational therapeutic strategies, and knowledge gaps in this condition.

Keywords

Coronary microvascular

Coronary vasospasm

Myocardial ischemia

Endothelial dysfunction

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