Systematic invasive assessment in selected INOCA/ANOCA patients safely identified abnormal coronary flow reserve in 70.8% and vasospastic angina in 54.2% of cases.
Does a systematic invasive coronary microvascular dysfunction assessment program safely and effectively diagnose INOCA/ANOCA in highly selected patients?
Implementation of a systematic invasive CMD assessment program in highly selected INOCA/ANOCA patients is safe and yields a diagnostic rate of approximately 70%.
Absolute Event Rate: 0% vs 0%
Abstract Introduction Patients with non-obstructive coronary artery disease (INOCA/ANOCA) are gaining attention as understanding of coronary microvascular dysfunction (CMD) grows. Expanding use of coronary flow reserve (CFR), index of microcirculatory resistance (IMR), and acetylcholine (ACh) testing broadens diagnostic pathways. Our large university cardiology center launched a dedicated INOCA/ANOCA diagnostic program at highly selected patients in March 2025. Our abstract focuses on the preliminary results of this ongoing project, demonstrating how to establish a systematic CMD assessment program while characterizing the demographic and clinical profile of patients undergoing invasive coronary assessment. Methods We established a structured CMD assessment program with patient selection criteria focusing on suspected microvascular or vasospastic etiology, with further assessment of the Seattle Angina Questionnaire. Main rationale of patient enrollment was exclusion of obstructive CAD in ICA or CCTA with equivocal presented symptoms or suspected microcoronary dysfunction in SPECT-MPI. Since setting up the program in March 2025, 24 patients underwent systematic evaluation including clinical assessment, echocardiography, and invasive microvascular testing. Every patient would be a candidate for the dynamic SPECT-MPI assessment of the MFR. Demographic characteristics, cardiovascular comorbidities, vasospastic angina (VSA) presence, and microvascular parameters were analyzed. Abnormal CFR was defined as ≤2.5, and IMR as 25. Importantly, the Ach provocative testing required obtaining the approval of the local Bioethics Committee due to off-label intracoronary administration of ACh beyond the registered indications. Results Our selected cohort demonstrated mean patient age of 64.9±9.8 years, 50% women, and mean BMI 30.0±5.7 kg/m². Most common cardiovascular comorbidities were: hypertension (83.3%), dyslipidemia (79.2%), and obesity (62.5%). Microvascular assessment: Mean CFR was 2.30±1.29, and IMR 26.9±23.3. Abnormal CFR (≤2.5) was observed in 17 patients (70.8%), and elevated IMR (25) in 9 patients (37.5%). VSA was documented in 13 patients (54.2%). Importantly, all patients with CCS class 3 (n=4) demonstrated abnormal CFR (≤2.5). IMR was higher in men compared with women (28.0 vs 14.5; p=0.056). Program safety and feasibility: No serious adverse events occurred during microcirculation assessment and acetylcholine testing. Most common adverse reaction was the temporary AV block, self-terminating. Conclusions Implementation of a systematic CMD assessment program in highly selected INOCA/ANOCA patients provides diagnostic rates of approximately 70%, validating our patient selection strategy. The observed associations and preliminary results confirm the value of such an approach. However, wide adoption of this diagnostic pathway remains challenging due to the need for Bioethics Committee approval for off-label intracoronary administration of ACh.
Cmiel et al. (Sun,) reported a other. Systematic invasive assessment in selected INOCA/ANOCA patients safely identified abnormal coronary flow reserve in 70.8% and vasospastic angina in 54.2% of cases.