Thread by @Gurleen_Kaur96

1/ #ASPC2021 Day 2 continues!

@DrMarthaGulati presents on Ischemic Heart Disease Without Obstructive Coronary Arteries (INOCA)

Follow this🧵on INOCA:
♦️Outcomes
♦️Mechanisms of ischemia and diagnosis
♦️Guidelines

@ASPCardio @CardioNerds

2/ Definition of INOCA: symptoms of ischemia in the absence of obstructive CAD or flow-limited disease

Check out this great infographic by @najahakhan, @CardioNerds Academy Fellow, on INOCA

#ASPC2021

3/ ✨Obstructive CAD is just one phenotype of IHD✨

INOCA – often normal LVEF, originally thought ischemia not present

But data shows elevated risk for cardiac events➡️poor outcomes

Guidelines haven’t caught up yet – focus on obstructive lesions

#ASPC2021

4/ GUSTO trial – over 30% of women had non-obstructive lesions in UA group.

ACC CathPCI registry (stable ischemic heart disease & ACS)➡️women more likely to have non-obstructive disease. And worse outcomes in women. bit.ly/2UDoXb4

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5/ WISE study - INOCA pts more likely to have CV events irrespective of risk factors

🔥INOCA is not benign🔥

♂️ obstructive CAD
♀️ microvascular disease, endothelial dysfunction

No obstructive CAD➡️can be more diffuse atherosclerosis, vasospasm, etc

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6/ Mechanisms of ischemia
Myocardial bridging, metabolic, systemic inflammation, metabolic abnormalities, coag abnormalities

If none above: consider INOCA, microvascular angina, vasospastic

Coronary circulation – not just epicardial arteries
pubmed.ncbi.nlm.nih.gov/29030424/

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7/ CorMicA trial – invasive coronary function testing➡️improvement in angina score & QOL

European guidelines: bit.ly/2UB3tM1

MINOCA Diagnosis
-AMI criteria
-non-obstructive coronaries on angiography, no stenosis >50%
-no clinically overt specific cause

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8/ Important to consider INOCA/MINOCA (MI w/ no obstructive CAD) as syndromes, NOT diagnoses

-Coronary microvascular
-Plaque rupture/erosion
-In-situ thrombosis
-SCAD
-Vasospasm
-Non-ischemic: stress cardiomyopathy, myocarditis

AHA statement: bit.ly/3zB6XNj

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9/ Next steps – cardiac MRI to investigate subendocardial ischemia, PET, coronary functional testing, etc

ESC guidelines: academic.oup.com/eurheartj/arti…

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10/ HARP study – multi modality imaging (OCT + CMR) for diagnosis, underlying etiology found in 85% of women with MINOCA

MINOCA is not benign

❤️‍🔥Treatment❤️‍🔥
Swedeheart cohort:➕effect w/ GDMT (statin, ACE/ARB), trend towards ➕ w/ beta-blocker, neutral effect w/ DAPT

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11/ INOCA Summary

🔴Not all IHD is obstructive
🔴Syndrome, not a final diagnosis
🔴Not benign
🔴Diagnosis requires additional investigations, effective risk stratification (functional + anatomical)
🔴For treatment, need further research specific to disease process

#ASPC2021