Advertisement
Canadian Journal of Cardiology

Temporal Trends of the Prevalence of Angina With No Obstructive Coronary Artery Disease (ANOCA)

Published:October 20, 2022DOI:https://doi.org/10.1016/j.cjca.2022.10.018

      Abstract

      Background

      Angina with no obstructive coronary artery disease (ANOCA) is a common entity. There is still under-recognition of this condition, but it is unclear if the referral patterns for chest pain diagnosis have changed. We aimed to determine if the prevalence of patients diagnosed with ANOCA by means of coronary angiography has changed over time.

      Methods

      A population-based cohort of patients who had their first coronary angiogram for a chest pain syndrome in Alberta from 1995 to 2020 was extracted retrospectively from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. A temporal trend analysis was performed to compare patients with ANOCA vs obstructive coronary artery disease (CAD), and the predictors of ANOCA were investigated.

      Results

      In our analysis, 121,066 patients were included (26% ANOCA, 31% female, overall mean age 62 years). The percentages of ANOCA vs obstructive CAD ranged from 24.2% to 26.7% in all patients (P < 0.001), from 19.4% to 21.4% in patients with acute coronary syndromes (P = 0.002), and from 30.6% to 37.5% in patients with stable angina (P < 0.001). Independent predictors of ANOCA were female sex (odds ratio [OR] 3.34, 95% confidence interval [CI] 3.05-3.66), younger age (OR 0.96, 95% CI 0.95-0.96), history of atrial fibrillation (OR 2.18, 95% CI 1.73-2.73), and stable angina (vs myocardial infarction: OR 0.25, 95% CI 0.23-0.28; vs unstable angina: OR 0.79, 95% CI 0.70-0.89). Traditional cardiovascular risk factors were associated with obstructive CAD.

      Conclusions

      There remained a high prevalence of ANOCA detected during invasive coronary angiography, which remained stable over time. This study demonstrates an opportunity to exclude obstructive CAD with less invasive testing, particularly in women.

      Résumé

      Contexte

      L’angine sans coronaropathie obstructive (ASCO) est une entité fréquemment observée. Ce syndrome demeure méconnu, mais il est difficile de dire si les schémas d’orientation diagnostique des patients présentant des douleurs thoraciques ont changé. Nous avons voulu déterminer si la prévalence de l’ASCO diagnostiqué par coronarographie a changé au fil du temps.

      Méthodologie

      Une cohorte populationnelle de patients ayant subi une première coronarographie en Alberta de 1995 à 2020 en raison d’un syndrome de douleur thoracique a été formée à partir des renseignements extraits rétrospectivement de la base de données APPROACH (Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease). Une analyse des tendances temporelles a été réalisée en vue d’établir une comparaison entre les patients atteints d’ASCO et ceux atteints de coronaropathies obstructives (CO), et les facteurs prédictifs d’ASCO ont été étudiés.

      Résultats

      Notre analyse portait sur 121 066 patients (26 % présentaient une ASCO et 31 % étaient des femmes; l’âge moyen global des patients était de 62 ans). La proportion de cas d’ASCO par rapport aux cas de CO allait de 24,2 à 26,7 % chez tous les patients (P = 0,001), de 19,4 à 21,4 % chez les patients présentant des syndromes coronariens aigus (P = 0,002) et de 30,6 à 37,5 % chez les patients présentant une angine stable (P < 0,001). Les facteurs prédictifs indépendants d’ASCO étaient le sexe féminin (rapport de cotes [RC] : 3,34, intervalle de confiance [IC] à 95 % : 3,05-3,66), le jeune âge (RC : 0,96, IC à 95 % : 0,95-0,96), les antécédents de fibrillation auriculaire (RC : 2,18, IC à 95 % : 1,73-2,73) et l’angine stable (vs l’infarctus du myocarde : RC : 0,25, IC à 95 % : 0,23-0,28; vs l’angine instable : RC : 0,79, IC à 95 % : 0,70-0,89). Les facteurs de risque cardiovasculaire classiques étaient associés à la CO.

      Conclusions

      La prévalence de l’ASCO détecté par coronarographie invasive est demeurée élevée et stable au fil du temps. Cette étude démontre qu’il est possible d’exclure un diagnostic de CO par des méthodes moins invasives, en particulier chez les femmes.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Bairey Merz C.N.
        • Pepine C.J.
        • Walsh M.N.
        • Fleg J.L.
        Ischemia and no obstructive coronary artery disease (INOCA): developing evidence-based therapies and research agenda for the next decade.
        Circulation. 2017; 135: 1075-1092
        • Konst R.E.
        • Meeder J.G.
        • Wittekoek M.E.
        • et al.
        Ischemia with no obstructive coronary arteries.
        Neth Heart J. 2020; 28: 66-72
        • Corcoran D.
        • Ford T.J.
        • Hsu L.Y.
        • et al.
        Rationale and design of the Coronary Microvascular Angina Cardiac Magnetic Resonance Imaging (CorCMR) diagnostic study: the CorMicA CMR sub-study.
        Open Heart. 2018; 5e000924
        • Jespersen L.
        • Hvelplund A.
        • Abildstrøm S.Z.
        • et al.
        Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events.
        Eur Heart J. 2012; 33: 734-744
        • Patel M.R.
        • Peterson E.D.
        • Dai D.
        • et al.
        Low diagnostic yield of elective coronary angiography.
        N Engl J Med. 2010; 362: 886-895
        • Sedlak T.L.
        • Lee M.
        • Izadnegahdar M.
        • Merz C.N.
        • Gao M.
        • Humphries K.H.
        Sex differences in clinical outcomes in patients with stable angina and no obstructive coronary artery disease.
        Am Heart J. 2013; 166: 38-44
        • Kissel C.K.
        • Chen G.
        • Southern D.A.
        • Galbraith P.D.
        • Anderson T.J.
        APPROACH Investigators. Impact of clinical presentation and presence of coronary sclerosis on long-term outcome of patients with nonobstructive coronary artery disease.
        BMC Cardiovasc Disord. 2018; 18: 173
        • Jespersen L.
        • Abildstrom S.Z.
        • Hvelplund A.
        • et al.
        Burden of hospital admission and repeat angiography in angina pectoris patients with and without coronary artery disease: a registry-based cohort study.
        PLoS One. 2014; 9e93170
        • Ghali W.A.
        • Knudtson M.L.
        APPROACH Investigators. Overview of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease.
        Can J Cardiol. 2000; 16: 1225-1230
        • Southern D.A.
        • James M.T.
        • Wilton S.B.
        • et al.
        Expanding the impact of a longstanding Canadian cardiac registry through data linkage: challenges and opportunities.
        Int J Popul Data Sci. 2018; 3: 9
        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • et al.
        Fourth Universal Definition of Myocardial Infarction (2018).
        Circulation. 2018; 138: e618-e651
        • Ford T.J.
        • Stanley B.
        • Good R.
        • et al.
        Stratified medical therapy using invasive coronary function testing in angina.
        J Am Coll Cardiol. 2018; 72: 2841-2855
        • Shaw J.
        • Anderson T.
        Coronary endothelial dysfunction in nonobstructive coronary artery disease: risk, pathogenesis, diagnosis and therapy.
        Vasc Med. 2016; 21: 146-155
        • Rahman H.
        • Corcoran D.
        • Aetesam-ur-Rahman M.
        • et al.
        Diagnosis of patients with angina and nonobstructive coronary disease in the catheter laboratory.
        Heart. 2019; 105: 1536-1542
        • Beltrame J.F.
        • Tavella R.
        • Jones D.
        • Zeitz C.
        Management of ischemia with nonobstructive coronary arteries (INOCA).
        BMJ. 2021; 375e060602
        • Shaw L.J.
        • Merz C.N.B.
        • Pepine C.J.
        • et al.
        The economic burden of angina in women with suspected ischemic heart disease.
        Circulation. 2006; 114: 894-904
      1. Kim I, Field TS, Wan D, Humphries K, Sedlak T. Sex and gender bias as a mechanistic determinant of cardiovascular disease outcomes [e-pub ahead of print]. Can J Cardiol 2022 Sep 15. doi:10.1016/j.cjca.2022.09.009

        • Gehrie E.R.
        • Reynolds H.R.
        • Chen A.Y.
        • et al.
        Characterisation and outcomes of women and men with non–ST-segment elevation myocardial infarction and nonobstructive coronary artery disease: results from the CAN Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative.
        Am Heart J. 2009; 158: 688-694
        • De Ferrari G.M.
        • Fox K.A.
        • White J.A.
        • et al.
        Outcomes among non–ST-segment elevation acute coronary syndromes patients with no angiographically obstructive coronary artery disease: observations from 37,101 patients.
        Eur Heart J Acute Cardiovasc Care. 2014; 3: 37-45
        • Reynolds H.R.
        • Maehara A.
        • Kwong R.Y.
        • et al.
        Coronary optical coherence tomography and cardiac magnetic resonance imaging to determine underlying causes of myocardial infarction with nonobstructive coronary arteries in women.
        Circulation. 2021; 143: 624-640
        • Roe M.T.
        • Harrington R.A.
        • Prosper D.M.
        • et al.
        Clinical and therapeutic profile of patients presenting with acute coronary syndromes who do not have significant coronary artery disease.
        Circulation. 2000; 102: 1101-1106
        • Patel M.R.
        • Dai D.
        • Hernandez A.F.
        • et al.
        Prevalence and predictors of nonobstructive coronary artery disease identified with coronary angiography in contemporary clinical practice.
        Am Heart J. 2014; 167: 846-852.e2
        • Khurram I.M.
        • Maqbool F.
        • Berger R.D.
        • et al.
        Association between left atrial stiffness index and atrial fibrillation recurrence in patients undergoing left atrial ablation.
        Circ Arrhythm Electrophysiol. 2016; 9e003163
        • Yoshida Y.
        • Nakanishi K.
        • Daimon M.
        • et al.
        Association of arterial stiffness with left atrial structure and phasic function: a community-based cohort study.
        J Hypertens. 2020; 38: 1140-1148
        • Packer M.
        • Lam C.S.P.
        • Lund L.H.
        • Redfield M.M.
        Interdependence of atrial fibrillation and heart failure with a preserved ejection fraction reflects a common underlying atrial and ventricular myopathy.
        Circulation. 2020; 141: 4-6
        • Kim M.N.
        • Park S.M.
        Heart failure with preserved ejection fraction: insights from recent clinical researches.
        Korean J Intern Med. 2020; 35: 514-534
        • Kunadian V.
        • Chieffo A.
        • Camici P.G.
        • et al.
        An EAPCI expert consensus document on ischemia with non-obstructive coronary arteries in collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group.
        EuroIntervention. 2021; 16: 1049-1069
        • Grundy S.M.
        • Stone N.J.
        • Bailey A.L.
        • et al.
        2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol.
        J Am Coll Cardiol. 2019; 73: e285-e350
        • Pacheco C.
        • Mullen K.A.
        • Coutinho T.
        • et al.
        The Canadian Women’s Heart Health Alliance atlas on the epidemiology, diagnosis, and management of cardiovascular disease in women—chapter 5: sex- and gender-unique manifestations of cardiovascular disease.
        CJC Open. 2022; 4: 243-262