Coronary flow velocity reserve predicts adverse prognosis in women with angina and no obstructive coronary artery disease: results from the iPOWER study

Abstract Aims Many patients with angina, especially women, do not have obstructive coronary artery disease (CAD) yet have impaired prognosis. We investigated whether routine assessment of coronary microvascular dysfunction (CMD) is feasible and predicts adverse outcome in women with angina and no obstructive CAD. Methods and results After screening 7253, we included 1853 women with angina and no obstructive CAD on angiogram who were free of previous CAD, heart failure, or valvular heart disease in the prospective iPOWER (Improving Diagnosis and Treatment of Women with Angina Pectoris and Microvascular Disease) study. CMD was assessed by Doppler echocardiography in the left anterior descending artery as coronary flow velocity reserve (CFVR). Patients were followed for a composite outcome of cardiovascular death, myocardial infarction (MI), heart failure, stroke, and coronary revascularization. CFVR was obtained in 1681 patients (91%) and the median CFVR was 2.33 (quartiles 1–3: 2.00–2.74). During a median follow-up of 4.5 years, 96 events occurred. In univariate Cox regression, CFVR was associated with the composite outcome {hazard ratio (HR) 1.07 [95% confidence interval (CI) 1.03–1.11] per 0.1 unit decrease in CFVR; P < 0.001}, primarily driven by an increased risk of MI and heart failure. Results remained significant in multivariate analysis [HR 1.05 (95% CI 1.01–1.09) per 0.1 unit decrease in CFVR; P = 0.01]. In exploratory analyses, CFVR was also associated with the risk of repeated hospital admission for angina and all-cause mortality. Conclusion Assessment of CFVR by echocardiography is feasible and predictive of adverse outcome in women with angina and no obstructive CAD. Results support a more aggressive preventive management of these patients and underline the need for trials targeting CMD.

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Coronary flow velocity reserve predicts adverse outcome in patients with angina and no obstructive coronary artery disease

European Heart Journal ◽

10.1093/ehjci/ehaa946.1287 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J Schroder ◽

M.M Michelsen ◽

N.D Mygind ◽

D Frestad ◽

H.E Suhrs ◽

...

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Coronary Artery Disease ◽

Coronary Flow ◽

Adverse Outcome ◽

Obstructive Coronary Artery Disease ◽

Funding Source ◽

Coronary Flow Velocity Reserve ◽

Coronary Flow Velocity ◽

Artery Disease

Abstract Background Many patients with angina do not have obstructive coronary artery disease (CAD) when evaluated with coronary angiography. It is unknown whether echocardiographic coronary flow velocity reserve (CFVR) predicts an adverse outcome in these subjects. Previous CFVR studies have included heterogeneous patient subtypes both with and without CAD. Purpose To assess whether reduced CFVR predicts adverse outcome in women with angina and no CAD. Methods We evaluated 1853 women with angina and a coronary angiogram without stenosis. Exclusion criteria were previous myocardial infarction, coronary revascularisation, heart failure or valvular disease. Coronary microvascular function was assessed by echocardiographic CFVR. All patients were followed up for major adverse cardiovascular events. Results CFVR was obtained in 1681 patients (91%), median CFVR was 2.33 (IQR 2.00–2.74). During a median follow-up of 4.48 years, 96 adverse events occurred (acute myocardial infarction: 25; heart failure: 21; revascularisation: 8; stroke: 32; cardiovascular death: 10). In univariate Cox regression, CFVR (hazard ratio [HR] 2.04 [95% CI 1.39–2.94] per unit decrease in CFVR; p<0.001), hypertension (HR 2.29 [95% CI 1.46–3.59]; p<0.001) and diabetes (HR 2.13 [95% CI 1.31–3.45]; p=0.002) were associated with adverse outcome. These associations remained in age-adjusted multivariable regression. Exploratory analyses identified CFVR=2.24 as the optimal discriminating threshold. Stratification according to reduced CFVR and hypertension identified subgroups with better, intermediate and worse outcome (Figure 1). Outcome analyses excluding stroke yielded similar results. Conclusion Impaired CFVR predicts adverse outcome in women with angina and no CAD. Integrating CFVR and hypertension identifies high-risk patients. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): The Danish Heart Foundation

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Transthoracic Assessment of Coronary Flow Velocity Reserve: A Practical Approach to Diagnostic Testing in Patients with Angina and No Obstructive Coronary Artery Disease

Journal of Interventional Cardiology ◽

10.1155/2021/6689312 ◽

2021 ◽

Vol 2021 ◽

pp. 1-8

Author(s):

Daria Frestad Bechsgaard ◽

Eva Prescott

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Flow Velocity ◽

Coronary Flow ◽

Obstructive Coronary Artery Disease ◽

Coronary Microvascular Dysfunction ◽

Coronary Flow Velocity Reserve ◽

Transthoracic Doppler Echocardiography ◽

Coronary Flow Velocity ◽

Artery Disease

More than half of the patients with symptoms suggestive of myocardial ischemia presenting at invasive angiography have no obstructive coronary artery disease (CAD). A large proportion of these patients have ischemia caused by coronary microvascular dysfunction, a condition associated with adverse cardiovascular prognosis. Measurement of coronary flow velocity reserve by transthoracic Doppler echocardiography is a feasible and reproducible method for the evaluation of coronary microvascular function. This review provides a practical overview of the method in a clinical setting of angina and noobstructive CAD, including technical details and prognostic significance.

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