June 1, 2021Open Access
View Full PaperNatural History of Patients With Ischemia and No Obstructive Coronary Artery Disease
Structured PICO
Does the change in echocardiographic ischemia correlate with the change in angina symptoms over 1 year in patients with INOCA?
P
Population
Patients with a history of angina and ischemia with no obstructive coronary artery disease (INOCA) who were screen failures in the ISCHEMIA trial, international cohort.
I
Intervention
Observation over 1 year with medical therapy at the discretion of treating physicians.
C
Comparator
ISCHEMIA trial participants with obstructive coronary artery disease (for comparison of inducible wall motion abnormalities).
O
Outcome
Correlation between the changes in the Seattle Angina Questionnaire angina frequency score and changes in echocardiographic ischemia at 1 year.patient reported
In patients with INOCA, changes in echocardiographic ischemia over 1 year do not correlate with changes in angina symptoms, highlighting the multifactorial nature of angina in this population.
Abstract
BACKGROUND: Ischemia with no obstructive coronary artery disease (INOCA) is common and has an adverse prognosis. We set out to describe the natural history of symptoms and ischemia in INOCA. METHODS: CIAO-ISCHEMIA (Changes in Ischemia and Angina over One Year in ISCHEMIA Trial Screen Failures With INOCA) was an international cohort study conducted from 2014 to 2019 involving angina assessments (Seattle Angina Questionnaire) and stress echocardiograms 1 year apart. This was an ancillary study that included patients with a history of angina who were not randomly assigned in the ISCHEMIA trial. Stress-induced wall motion abnormalities were determined by an echocardiographic core laboratory blinded to symptoms, coronary artery disease status, and test timing. Medical therapy was at the discretion of treating physicians. The primary outcome was the correlation between the changes in the Seattle Angina Questionnaire angina frequency score and changes in echocardiographic ischemia. We also analyzed predictors of 1-year changes in both angina and ischemia, and we compared CIAO participants with ISCHEMIA participants with obstructive coronary artery disease who had stress echocardiography before enrollment, as CIAO participants did. RESULTS: =0.35). At 1 year, the stress echocardiogram was normal in half of CIAO participants, and 23% had moderate or severe ischemia (≥3 ischemic segments). Angina improved in 43% and worsened in 14%. Change in ischemia over 1 year was not significantly correlated with change in angina (ρ=0.029). CONCLUSIONS: Improvement in ischemia and angina were common in INOCA but not correlated. Our INOCA cohort had a degree of inducible wall motion abnormalities similar to concurrently enrolled ISCHEMIA participants with obstructive coronary artery disease. Our results highlight the complex nature of INOCA pathophysiology and the multifactorial nature of angina. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02347215.