Angina with no obstructed coronary arteries fileAngina with no obstructed coronary arteries Eva...

Angina with no obstructed coronary arteries

Eva Prescott, MD, DMScDepartment of Cardiology

Bispebjerg HospitalUniversity of Copenhagen

Bispebjerg University Hospital

I have nothing to declare

Department of Cardiology, Bispebjerg University Hospital

Standardized mortality rates from ischaemic heart disease in selected European countriesPer 100.000, World Health Organization

Standardised 30 days and 365 days mortality after first MI

Mortality has been reduced by 50% in all groups

Schmidt et al, BMJ 2012

Improvement in survival after MI

30d and 1-yr mortality 1984-2008, Denmark

DEPARTMENT OF CARDIOLOGY, BISPEBJERG UNIVERSITY HOSPITAL

Patients who survive the first month after an STEMI treated with primary PCI have an

excellent prognosis, with a


How common is angina with no obstructive CAD?

What is prognosis in terms of CV outcome?

What is prognosis in terms of continued symptoms, health related quality of life and disability?

What are the costs to society?


Figure 1. Angina prevalence in women vs men.

Harry Hemingway et al. Circulation. 2008;117:1526-1536

Copyright © American Heart Association, Inc. All rights reserved.

Population weighted

mean 6.7%

Femalemale ratio

1.2

Angina with no obstructive CAD:Prognosis, disability and costs

Angina and NOCAD

Continuedsymptoms

Depression, anxiety

Health related

Quality of life

Disability

CostsDirect and

indirect

CV morbidity Patients

perspective

Societal perspective

Cardiologist perspective


In ACS women twice as often as men have nosignificant CAD

Data from 11 randomised studies 1993-2006 comprising 35.000 persons

Berger at al, JAMA 2009;302:874-82

Rate of NOCAD from clinically indicated angiograms

Patel et al, NEJM 2010

398,978 patients without known CAD undergoing elective CAG

37.6% obstructive CAD (>50% stenosis of LM, >70% of major epicardial vessel)

Men: 47%

Women: 27%


How common is no obstructive CAD in stable angina?

Danish data: 11,000 persons without known CVD referred to angiography because of stable angina.

Proportion with and without obstructive CAD in the period 2000-2009

Jespersen L, European Heart Journal, 2012

The PROMISE trial – of 10.000 patients assessed for CAD, 5% were ultimately revascularized


Angina with obstructive CAD – tip of the iceberg?


Change of paradigm from purelymacrovascular to microvascular disease

0

20

40

60

80

100

Medical treatment Invasive treatment

baseline1 yr3 yr5 yr

Changing paradigm of angina and CAD with less focus on treatment of the epicardial

stenosis


Survival free of MACE (CV mortality, MI, HF or stroke) by degree of CAD in patients referred to CAG due to angina


Persistence of angina by degree of CAD

Follow up 2-3 years after first angiogram

Jespersen et al, Clin Res Cardiol, 2013

357 patients (response rate 83%)

with CAG due to angina reassessed by

Seattle angina questionnaire and Hospital Anxiety and Depression

Scale after 2-3 years


Persistance of angina at follow-up of patients referred to CAG for angina

010203040506070

Normal Diffuse CAD

1-2 VD

% persistent

angina

Men Women

Jespersen et al, Clin Res Cardiol, 2013

P

Persistent angina associated with depression and anxiety

Depression

Anxiety

Jespersen et al, Clin Res Cardiol,

2013


Quality of life determined by angina, not degree of CAD


Risk of disability pension and premature exit from workforce

Jespersen et al, EHJ 2013


Survival free of disability pension



Angina, NOCAD, CAD and subsequent risk of disability pension

Age-and gender

adjusted

Multivariable adjusted(co-morbidity,

socioeconomic factors, cardiac risk factors),



Burden of hospital admission in angina with and without CAD

Jespersen et al, PLOS one 2014


Burden of CV hospitalization: Comparing repeated events risk by angiography findingrecurrent event models


Adjusted for age, gender, risk factors, medication, co-morbidity, ses


Burden of CV hospitalization: Comparing repeated events risk by angiography finding




How common is angina with no obstructive CAD?Depends on diagnostic work-upTwice as common in women as in men

What is prognosis in terms of CV outcome?Depends on comparison groupDiffers between populations depending on referral patternsIs poorer than the background population

What is prognosis in terms of continued symptoms, healthrelated quality of life and disability?Symptoms and disability similar across CAG findingsSymptom persistence drives QoL

What are the costs to society?Considerable


Thank you for your attention


Angina with no obstructed coronary arteriesI have nothing to declare�Standardized mortality rates from ischaemic heart disease in selected European countries�Per 100.000, World Health OrganizationFoliennummer 4Foliennummer 5Angina with no obstructed coronary arteriesFoliennummer 7Angina with no obstructive CAD:�Prognosis, disability and costsIn ACS women twice as often as men have no significant CADRate of NOCAD from clinically indicated angiogramsHow common is no obstructive CAD in stable angina?Foliennummer 12Angina with obstructive CAD – tip of the iceberg?Change of paradigm from purely macrovascular to microvascular diseaseFoliennummer 15Persistence of angina by degree of CAD��Follow up 2-3 years after first angiogramPersistance of angina at follow-up of patients referred to CAG for angina Persistent angina associated with depression and anxietyQuality of life determined by angina, not degree of CADRisk of disability pension and premature exit from workforceSurvival free of disability pensionAngina, NOCAD, CAD and subsequent risk of disability pensionBurden of hospital admission in angina with and without CADBurden of CV hospitalization: Comparing repeated events risk by angiography finding�recurrent event modelsBurden of CV hospitalization: Comparing repeated events risk by angiography findingAngina with no obstructed coronary arteriesFoliennummer 27

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