Stable coronary syndromes: pathophysiology, diagnostic advances and therapeutic need

Ford, T. J. , Corcoran, D. and Berry, C. (2018) Stable coronary syndromes: pathophysiology, diagnostic advances and therapeutic need. Heart, 104(4), pp. 284-292. (doi:10.1136/heartjnl-2017-311446) (PMID:29030424)

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Abstract

The diagnostic management of patients with angina pectoris typically centres on the detection of obstructive epicardial CAD, which aligns with evidence-based treatment options that include medical therapy and myocardial revascularisation. This clinical paradigm fails to account for the considerable proportion (approximately one-third) of patients with angina in whom obstructive CAD is excluded. This common scenario presents a diagnostic conundrum whereby angina occurs but there is no obstructive CAD (ischaemia and no obstructive coronary artery disease—INOCA). We review new insights into the pathophysiology of angina whereby myocardial ischaemia results from a deficient supply of oxygenated blood to the myocardium, due to various combinations of focal or diffuse epicardial disease (macrovascular), microvascular dysfunction or both. Macrovascular disease may be due to the presence of obstructive CAD secondary to atherosclerosis, or may be dynamic due to a functional disorder (eg, coronary artery spasm, myocardial bridging). Pathophysiology of coronary microvascular disease may involve anatomical abnormalities resulting in increased coronary resistance, or functional abnormalities resulting in abnormal vasomotor tone. We consider novel clinical diagnostic techniques enabling new insights into the causes of angina and appraise the need for improved therapeutic options for patients with INOCA. We conclude that the taxonomy of stable CAD could improve to better reflect the heterogeneous pathophysiology of the coronary circulation. We propose the term ‘stable coronary syndromes’ (SCS), which aligns with the well-established terminology for ‘acute coronary syndromes’. SCS subtends a clinically relevant classification that more fully encompasses the different diseases of the epicardial and microvascular coronary circulation.

Item Type:Articles
Status:Published
Refereed:Yes
Glasgow Author(s) Enlighten ID:Berry, Professor Colin and Corcoran, Dr David and Ford, Thomas
Authors: Ford, T. J., Corcoran, D., and Berry, C.
College/School:College of Medical Veterinary and Life Sciences > Institute of Cardiovascular and Medical Sciences
Journal Name:Heart
Publisher:BMJ Publishing Group
ISSN:1355-6037
ISSN (Online):1468-201X
Published Online:13 October 2017
Copyright Holders:Copyright © 2017 The Authors
First Published:First published in Heart 104(4): 284-292
Publisher Policy:Reproduced under a Creative Commons License

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Project CodeAward NoProject NamePrincipal InvestigatorFunder's NameFunder RefLead Dept
628691Microvascular Dysfunction in Patients with Angina: The CE-MARC2 Microvascular SubstudyColin BerryBritish Heart Foundation (BHF)FS/14/15/30661RI CARDIOVASCULAR & MEDICAL SCIENCES
617771BHF centre of excellenceRhian TouyzBritish Heart Foundation (BHF)RE/13/5/30177RI CARDIOVASCULAR & MEDICAL SCIENCES
757351The conundrum of angina in patients without obstructive coronary disease: a randomised controlled pilot trial of routine testing of coronary function.Colin BerryBritish Heart Foundation (BHF)FS/17/26/32744RI CARDIOVASCULAR & MEDICAL SCIENCES