Stable Coronary Syndromes: The Case for Consolidating the Nomenclature of Stable Ischemic Heart Disease
2017; Lippincott Williams & Wilkins; Volume: 136; Issue: 5 Linguagem: Inglês
10.1161/circulationaha.117.028991
ISSN1524-4539
Autores Tópico(s)Cardiac Health and Mental Health
ResumoHomeCirculationVol. 136, No. 5Stable Coronary Syndromes: The Case for Consolidating the Nomenclature of Stable Ischemic Heart Disease Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBStable Coronary Syndromes: The Case for Consolidating the Nomenclature of Stable Ischemic Heart Disease Colin Berry, MD, PhD Colin BerryColin Berry From British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom; and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom. Originally published1 Aug 2017https://doi.org/10.1161/CIRCULATIONAHA.117.028991Circulation. 2017;136:437–439Angina pectoris, first described by William Heberden in the Royal College of Physicians, London, in 1768, is chest pain of cardiac origin. Despite being a symptom, angina is a disease-based diagnosis (International Classification of Diseases, I20). Practice guidelines use somewhat different terms. The nomenclature of the American guidelines includes chronic stable angina (2002) and stable ischemic heart disease (2012), whereas the guidelines of the European Society of Cardiology (2013) refer to stable coronary artery disease. Thus, there are multiple terms and abbreviations for stable ischemic heart disease and cohesion is lacking.By contrast, acute coronary syndrome is a unifying hierarchical term that subtends the distinct subgroups of unstable angina and myocardial infarction and is used consistently worldwide.The Conundrum of Angina in Patients with No Obstructive CadThe established diagnostic pathways for patients with suspected angina have been appropriately developed to identify obstructive coronary artery disease (CAD) with a view to evidence-based treatment. In recent years, however, multiple clinical studies have disclosed that more than one-third of symptomatic patients do not have obstructive CAD.1 Furthermore, ischemia may be substantial in this subgroup, and the prognosis is not benign.2Exclusion of obstructive CAD in a patient with angina presents a conundrum. Angina without obstructive CAD may be frustrating for the patient and the clinician, and, in the absence of a unifying diagnosis, treatment becomes empirical and potentially suboptimal. The lack of evidence from randomized controlled clinical trials in this subgroup underpins the heterogeneity in management.Sex Association With Ischemia and No Obstructive Coronary Disease and PrognosisSyndrome X is an historical term stigmatized by its associations with female sex, obesity, and psychology, leading to therapeutic nihilism in the minds of some clinicians. Although reductions in mortality attributable to coronary heart disease have been observed in recent decades, no such decline has been observed in younger (<55 years) women.3 The persistence of risk among younger women may be explained in part by impaired coronary flow reserve rather than obstructive CAD.1Given this vexing state of affairs,2,3 the recent white paper by Bairey Merz et al1 is a welcome development. The authors cite a new term for the subgroup of patients with ischemia and no obstructive CAD (INOCA [ischemia and no obstructive coronary artery disease]), the gaps in evidence, and areas for future research.Diagnostic Tests for Cad and Their Limitations for Identifying the Etiology of INOCAHistorically, anatomic and functional tests were developed for the detection of obstructive CAD and validated against the coronary angiogram. Increasingly, invasive examinations include adjunctive measurements, such as fractional flow reserve; however, neither angiography nor fractional flow reserve evaluate microvascular function.Given the clinical focus on obstructive CAD, only a minority of invasive cardiologists are competent in the use of interventional diagnostic procedures, including pharmacological tests of coronary endothelial function and vasospasm by intracoronary administration of acetylcholine and guidewire-based tests of coronary vasoreactivity (ie, coronary flow reserve) and microvascular resistance, respectively. This gap is underpinned by the lack of evidence from randomized trials that the use of such tests improves patient well-being and healthcare costs. Stress MRI and positron emission tomography have diagnostic utility for coronary microvascular dysfunction, but, as with the invasive diagnostic tests, evidence of patient benefits from randomized trials is lacking.An emerging focus on direct imaging of CAD is highlighted by the UK National Institute for Health and Care Excellence guideline-95 update (NICE-95; November 2016)4 that recommended CT coronary angiography (CTCA) as the first-line diagnostic test in patients with angina but without prior coronary heart disease. NICE-95 reflects the results from recent trials involving CTCA. Compared with functional testing, the use of CTCA is associated with an increased use of evidence-based therapy and, potentially, a reduction in the risk of myocardial infarction.Adoption of CTCA as a first-line test in patients with chest pain is increasing worldwide. In the United Kingdom, the NICE-95 update has major implications, not only regarding access to CTCA, but also for the management of symptomatic patients without obstructive CAD, the majority of whom are women. Some of these patients may have microvascular or vasospastic angina, and the exclusion of obstructive CAD by CTCA may lead to false reassurance.The SCOT-HEART study (Scottish Computed Tomography of the Heart) quality-of-life analysis highlights this conundrum.5 Symptoms and quality of life assessed at baseline and 6 months improved less in patients assigned to the CTCA-guided strategy than in those assigned to standard care. I was a member of the Trial Steering Committee, and this result was unexpected. One potential explanation could be false reassurance for those patients with INOCA, in whom angina therapy may have been discontinued. This analysis refuted the hypothesis that symptoms and quality of life would improve with a CTCA-guided strategy, and it conflicts with the NICE-95 update.The Case for Unifying TerminologyIn summary, the conundrums relating to the lack of decline in coronary heart disease mortality in younger women, inconsistent disease nomenclature, focus on anatomic imaging, heterogeneous management of disease subgroups (ie, INOCA and related gaps in clinical evidence), unexpected trial results, and controversial guideline recommendations are on my mind.The diagnostic classifier acute coronary syndrome is a significant term that subtends the distinct clinical presentations of patients with acute coronary disease. Considering stable ischemic heart disease and its disease subgroups, there is a critical lack of a unifying high-level classifier. In my opinion, this gap in terminology associates with some of the issues outlined above. In the absence of simple, consistent nomenclature, advances in our understanding of disease subgroups such as INOCA, which is a current hot topic in cardiology, are less well placed for translation into practice. Given the focus on obstructive CAD, this gap could potentially enhance underrecognition and undertreatment of patients with INOCA. The term acute coronary syndrome has high-level, unifying significance so it seems logical to propose the term stable coronary syndrome (Figure 1). This term would sit well in the hierarchical classification of ischemic heart disease and serve to highlight that angina is not synonymous with obstructive CAD and that a disorder of coronary artery function may be relevant.Download figureDownload PowerPointFigure. A hierarchical nomenclature of diagnostic terms for coronary disease subgroups that cause ischemic heart disease. Stable coronary syndromes and acute coronary syndromes are second-order terms that broadly encompass the ischemic heart disease subgroups, including obstructive and nonobstructive coronary artery disease, and disorders of coronary artery function, including microvascular and vasospastic angina. CAD indicates coronary artery disease; INOCA, ischemia and no obstructive coronary artery disease; MINOCA, myocardial infarction and no obstructive coronary artery disease; NSTEMI, non–ST-segment–elevation myocardial infarction; STEMI, ST-segment–elevation myocardial infarction; and UA, unstable angina.Sources of FundingThis work was supported by the British Heart Foundation, including a Centre of Research Excellence Award (RE/13/5/30177) and research fellowships (FS/14/15/30661; FS/17/26/32744).DisclosuresDr Berry is employed by the University of Glasgow which holds consultancy and research agreements with companies that have commercial interests in the diagnosis and treatment of angina. The companies include Abbott Vascular, AstraZeneca, Boehringer Ingelheim, Menarini Pharmaceuticals, and Siemens Healthcare.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at http://circ.ahajournals.org.Correspondence to: Colin Berry, MD, PhD, British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, 126 University Place, University of Glasgow, Glasgow, G12 8TA, Scotland, United Kingdom. E-mail [email protected]References1. Bairey Merz CN, Pepine CJ, Walsh MN, Fleg JL. Ischemia and no obstructive coronary artery disease (INOCA): developing evidence-based therapies and research agenda for the next decade.Circulation. 2017; 135:1075–1092. doi: 10.1161/CIRCULATIONAHA.116.024534.LinkGoogle Scholar2. Jespersen L, Hvelplund A, Abildstrøm SZ, Pedersen F, Galatius S, Madsen JK, Jørgensen E, Kelbæk 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; 33:734–744. doi: 10.1093/eurheartj/ehr331.CrossrefMedlineGoogle Scholar3. Wilmot KA, O'Flaherty M, Capewell S, Ford ES, Vaccarino V. Coronary heart disease mortality declines in the United States from 1979 through 2011: evidence for stagnation in young adults, especially women.Circulation. 2015; 132:997–1002. doi: 10.1161/CIRCULATIONAHA.115.015293.LinkGoogle Scholar4. National Institute for Health and Care Excellence. Chest pain of recent onset: assessment and diagnosis. Clinical Guideline 95 (CG95).Published 2010; update November 2016. https://www.nice.org.uk/Guidance/CG95 Accessed May 12, 2017.Google Scholar5. Williams MC, Hunter A, Shah A, Assi V, Lewis S, Mangion K, Berry C, Boon NA, Clark E, Flather M, Forbes J, McLean S, Roditi G, van Beek EJ, Timmis AD, Newby DE; Scottish Computed Tomography of the Heart (SCOT-HEART) Trial Investigators. Symptoms and quality of life in patients with suspected angina undergoing CT coronary angiography: a randomised controlled trial.Heart. 2017; 103:995–1001. doi: 10.1136/heartjnl-2016-310129.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Tamargo J and Lopez-Sendon J (2022) Ranolazine: a better understanding of its pathophysiology and patient profile to guide treatment of chronic stable angina, Future Cardiology, 10.2217/fca-2021-0058, 18:3, (235-251), Online publication date: 1-Mar-2022. Reynolds H, Bairey Merz C, Berry C, Samuel R, Saw J, Smilowitz N, de Souza A, Sykes R, Taqueti V and Wei J (2022) Coronary Arterial Function and Disease in Women With No Obstructive Coronary Arteries, Circulation Research, 130:4, (529-551), Online publication date: 18-Feb-2022. Park T, Devi S, Sharma A, Kim G and Cho K (2022) De Novo Sphingolipid Biosynthesis in Atherosclerosis Sphingolipid Metabolism and Metabolic Disease, 10.1007/978-981-19-0394-6_3, (31-46), . Junqueira C, Ferreira E, Junqueira A, Cyrino F, Maranhão P, Kraemer-Aguiar L, Bottino D, de Souza M and Bouskela E Peripheral microvascular dysfunction is also present in patients with ischemia and no obstructive coronary artery disease (INOCA), Clinical Hemorheology and Microcirculation, 10.3233/CH-201065, 79:3, (381-393) Megna R, Assante R, Zampella E, Gaudieri V, Nappi C, Cuocolo R, Mannarino T, Genova A, Green R, Cantoni V, Acampa W, Petretta M and Cuocolo A (2019) Pretest models for predicting abnormal stress single-photon emission computed tomography myocardial perfusion imaging, Journal of Nuclear Cardiology, 10.1007/s12350-019-01941-3, 28:5, (1891-1902), Online publication date: 1-Oct-2021. Lopez-Sendon J, Moreno R and Tamargo J (2021) ISCHEMIA Trial: Key Questions and Answers, European Cardiology Review, 10.15420/ecr.2021.16, 16 Morrow A, Ford T, Mangion K, Kotecha T, Rakhit R, Galasko G, Hoole S, Davenport A, Kharbanda R, Ferreira V, Shanmuganathan M, Chiribiri A, Perera D, Rahman H, Arnold J, Greenwood J, Fisher M, Husmeier D, Hill N, Luo X, Williams N, Miller L, Dempster J, Macfarlane P, Welsh P, Sattar N, Whittaker A, Connachie A, Padmanabhan S and Berry C (2020) Rationale and design of the Medical Research Council's Precision Medicine with Zibotentan in Microvascular Angina (PRIZE) trial, American Heart Journal, 10.1016/j.ahj.2020.07.007, 229, (70-80), Online publication date: 1-Nov-2020. 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Raparelli V, Elharram M, Shimony A, Eisenberg M, Cheema A and Pilote L (2018) Myocardial Infarction With No Obstructive Coronary Artery Disease: Angiographic and Clinical Insights in Patients With Premature Presentation, Canadian Journal of Cardiology, 10.1016/j.cjca.2018.01.004, 34:4, (468-476), Online publication date: 1-Apr-2018. August 1, 2017Vol 136, Issue 5 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.028991PMID: 28760869 Originally publishedAugust 1, 2017 Keywordscoronary artery diseasecoronary circulationangina pectorisdiagnosisstandardsPDF download Advertisement SubjectsComputerized Tomography (CT)Coronary CirculationImagingIschemia
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