Long-term efficacy of endotype-based drug therapy on quality of life and symptom management in coronary vasomotion disorders

Background In patients with angina pectoris without obstructive coronary artery disease (ANOCA), coronary vasomotion disorders are a common cause for their symptoms. However, the heterogeneous clinical presentation resulting from a broad spectrum of subtypes (so-called endotypes) poses a major therapeutic challenge. Many patients suffer from long-term refractory symptoms and severely impaired quality of life. Purpose The purpose of this study was to evaluate the long-term benefits of an endotype-based drug therapy on quality of life and symptom management in ANOCA patients. Methods From the initial population of 50 patients (enrolled between 04/2021 and 02/2022) with a confirmed diagnosis of a coronary vasomotion disorder and subsequent targeted guideline-based endotype-adapted antianginal therapy, a total number of 38 patients (53% women, 65±15 years), were followed up over a period of 3 years (i.e. 76%). Initially, the efficacy and tolerability of the medications were closely monitored and adjusted over a period of 3 months. Thereafter, patients were offered outpatient visits if required. The quality of life was assessed quantitatively (score 0-100) using the Seattle Angina Questionnaire-7 (SAQ7) on a monthly basis during the 3-month therapy adjustment and at long-term follow-up after 3 years. Results The endotypes were classified according to the diagnostically distinguishable subtypes (coronary spasm: n=21; microvascular vasodilatation disorder: n=3; combined vasomotion disorder: n=14). The initial clinically relevant improvement in the SAQ7-Summary score by an average of 16 points after 3 months of endotype-based antianginal therapy (44±16 vs. 60±23; p<0.001) even persisted after 3 years (44±16 vs. 63±23; p<0.001). Of these patients, 63% experienced either further improvement in the clinically relevant range (>5 points; n=19) or no change (<5 points, n=5) after 3 years, while a clinically relevant aggravation (≥5 points) was recorded in 37% of the study population (n=14). Regarding the endotypes, 83% of the patients with isolated coronary spasm or vasodilation disorder benefited sustainably from targeted endotype-based therapy with an improved or unchanged SAQ7-Summary score. In patients with combined vasomotion disorders, long-term efficacy was only achieved in 29% of the patients. Comparing the medication after 3 years with the medication at 3-month follow-up under targeted therapy, patients reported a significant decrease in short-acting nitrate intake (p=0.021). For other antianginal drugs (calcium channel antagonists, long-acting nitrates, molsidomine, beta blockers, ranolazine) or basic treatment drugs (ACE inhibitors, statins) no significant changes were observed within the entire study population. Conclusion Targeted endotype-based drug therapy can contribute decisively to a long-term improvement of symptoms and quality of life, especially in ANOCA patients with isolated coronary spasm or microvascular vasodilation disorder.