The online version of this article (https://doi.org/10.1186/s12872-018-0908-z) contains supplementary material, which is available to authorized users.
Non-obstructive coronary artery disease (NOCAD) is a common finding on coronary angiography. Our goal was to evaluate the long-term prognosis of NOCAD patients with stable angina (SA).
The study cohort consisted of 7478 NOCAD patients with normal EF (≥ 50%), and SA who underwent coronary angiography between 1995 and 2012. We compared NOCAD patients (stenosis< 50%) with 10,906 patients with stable obstructive CAD (≥ 50%). The primary endpoint was all-cause mortality. Secondary endpoints included repeat angiography, progressive CAD, and PCI. A second comparison group consisted of 7344 patients with NOCAD presenting with an ACS. Rates of all-cause mortality of NOCAD ACS patients were compared to NOCAD SA patients.
Median follow-up time was 6.5 years. NOCAD patients had a lower risk of all-cause mortality compared to CAD patients (HR CAD vs. NOCAD 1.33 (1.19–1.49); p < 0.001). This was driven by patients with normal coronary arteries (HR CAD vs. normal 1.63 (1.36–1.94), p < 0.001), whereas patients with minimal disease (> 0% and < 50%) were at similar risk as CAD patients (HR CAD vs. minimal 1.08 (0.99–1.29), p = 0.06). In NOCAD patients, the strongest predictors of all-cause mortality were age and minimal disease. SA patients with NOCAD had low rates of repeat angiography (7.3%), future CAD (2.3%) and PCI (1.7%). NOCAD ACS patients had a 41% increase in all-cause mortality risk compared to NOCAD SA patients (HR 1.41 (1.25–1.6), p < 0.001).
This study underlines the importance of minimal CAD, as it is not a benign disease entity and portends a similar risk as stable obstructive CAD.
Additional file 1: Table S1. Comparison of Baseline Characteristics of Stable Angina Patients with NOCAD: normal coronaries vs. minimal disease. (DOCX 15 kb)12872_2018_908_MOESM1_ESM.docx
Shaw LJ, Shaw RE, Merz CN, Brindis RG, Klein LW, Nallamothu B, Douglas PS, Krone RJ, McKay CR, Block PC, et al. Impact of ethnicity and gender differences on angiographic coronary artery disease prevalence and in-hospital mortality in the American College of Cardiology-National Cardiovascular Data Registry. Circulation. 2008;117(14):1787–801. CrossRefPubMed
Sharaf B, Wood T, Shaw L, Johnson BD, Kelsey S, Anderson RD, Pepine CJ, Bairey Merz CN. Adverse outcomes among women presenting with signs and symptoms of ischemia and no obstructive coronary artery disease: findings from the National Heart, Lung, and Blood Institute-sponsored Women's ischemia syndrome evaluation (WISE) angiographic core laboratory. Am Heart J. 2013;166(1):134–41. CrossRefPubMedPubMedCentral
Jespersen L, Hvelplund A, Abildstrom SZ, Pedersen F, Galatius S, Madsen JK, Jorgensen E, Kelbaek H, Prescott E. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J. 2012;33(6):734–44. CrossRefPubMed
Maddox TM, Ho PM, Roe M, Dai D, Tsai TT, Rumsfeld JS. Utilization of secondary prevention therapies in patients with nonobstructive coronary artery disease identified during cardiac catheterization: insights from the National Cardiovascular Data Registry Cath-PCI registry. Circ Cardiovasc Qual Outcomes. 2010;3(6):632–41. CrossRefPubMed
Pepine CJ, Ferdinand KC, Shaw LJ, Light-McGroary KA, Shah RU, Gulati M, Duvernoy C, Walsh MN, Bairey Merz CN. Committee ACiW: emergence of nonobstructive coronary artery disease: a Woman's problem and need for change in definition on angiography. J Am Coll Cardiol. 2015;66(17):1918–33. CrossRefPubMedPubMedCentral
Gehrie ER, Reynolds HR, Chen AY, Neelon BH, Roe MT, Gibler WB, Ohman EM, Newby LK, Peterson ED, Hochman JS. Characterization and outcomes of women and men with non-ST-segment elevation myocardial infarction and nonobstructive coronary artery disease: results from the can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines (CRUSADE) quality improvement initiative. Am Heart J. 2009;158(4):688–94. CrossRefPubMed
De Ferrari GM, Fox KA, White JA, Giugliano RP, Tricoci P, Reynolds HR, Hochman JS, Gibson CM, Theroux P, Harrington RA, et al. Outcomes among non-ST-segment elevation acute coronary syndromes patients with no angiographically obstructive coronary artery disease: observations from 37,101 patients. Eur Heart J Acute Cardiovasc Care. 2014;3(1):37–45. CrossRefPubMedPubMedCentral
Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, De Caterina R, Zimarino M, Roffi M, Kjeldsen K, et al. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J. 2017;38(3):143–53. PubMed
Ghali WA, Knudtson ML. Overview of the Alberta provincial project for outcome assessment in coronary heart disease. On behalf of the APPROACH investigators. Can J Cardiol. 2000;16(10):1225–30. PubMed
Sharaf BL, Pepine CJ, Kerensky RA, Reis SE, Reichek N, Rogers WJ, Sopko G, Kelsey SF, Holubkov R, Olson M, et al. Detailed angiographic analysis of women with suspected ischemic chest pain (pilot phase data from the NHLBI-sponsored Women's ischemia syndrome evaluation [WISE] study angiographic Core Laboratory). Am J Cardiol. 2001;87(8):937–41. A933 CrossRefPubMed
Johnson BD, Shaw LJ, Pepine CJ, Reis SE, Kelsey SF, Sopko G, Rogers WJ, Mankad S, Sharaf BL, Bittner V, et al. Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease: results from the NIH-NHLBI-sponsored Women's Ischaemia syndrome evaluation (WISE) study. Eur Heart J. 2006;27(12):1408–15. CrossRefPubMed
Ong P, Athanasiadis A, Borgulya G, Mahrholdt H, Kaski JC, Sechtem U. High prevalence of a pathological response to acetylcholine testing in patients with stable angina pectoris and unobstructed coronary arteries. The ACOVA study (abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries). J Am Coll Cardiol. 2012;59(7):655–62. CrossRefPubMed
Min JK, Dunning A, Lin FY, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Cheng V, et al. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the international multicenter CONFIRM (coronary CT angiography evaluation for clinical outcomes: an international multicenter registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol. 2011;58(8):849–60. CrossRefPubMed
Lin FY, Shaw LJ, Dunning AM, Labounty TM, Choi JH, Weinsaft JW, Koduru S, Gomez MJ, Delago AJ, Callister TQ, et al. Mortality risk in symptomatic patients with nonobstructive coronary artery disease: a prospective 2-center study of 2,583 patients undergoing 64-detector row coronary computed tomographic angiography. J Am Coll Cardiol. 2011;58(5):510–9. CrossRefPubMed
Huang F-Y, Huang B-T, Lv W-Y, Liu W, Peng Y, Xia T-L, Wang P-J, Zuo Z-L, Liu R-S, Zhang C, et al. The prognosis of patients with nonobstructive coronary artery disease versus normal arteries determined by invasive coronary angiography or computed tomography coronary angiography: a systematic review. Medicine. 2016;95(11):e3117. CrossRefPubMedPubMedCentral
- Impact of clinical presentation and presence of coronary sclerosis on long-term outcome of patients with non-obstructive coronary artery disease
Christine K. Kissel
Danielle A. Southern
P. Diane Galbraith
Todd J. Anderson
for the APPROACH investigators
- BioMed Central
Neu im Fachgebiet Kardiologie
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