Invasive diagnosis of INOCA/ANOCA: coronary atherosclerosis and vasospastic angina as combined causes of myocardial ischemia, contemporary invasive diagnostics and treatment
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Abstract
The aim – to evaluate the safety and efficacy of the invasive acetylcholine provocation test for endotyping patients with INOCA/ANOCA, to determine the mechanisms of ischemia in cases where functional disorders coexist with coronary atherosclerosis, and to develop personalized treatment approaches.
Materials and methods. The study included 61 patients: experimental group A (n=42) and control group B (n=19) with symptoms of angina and objective signs of myocardial ischemia on ECG (primarily ST-segment depression or elevation during an exercise stress test) and coronary angiography findings. The groups were statistically comparable regarding demographic characteristics and cardiovascular risk factors. No significant differences were found between the groups in terms of age (p=0.57), sex (p=0.76), presence of arterial hypertension (p=0.68), diabetes mellitus (p>0.99), or dyslipidemia (p=0.37). The provocation test protocol involved a step-up intracoronary administration of acetylcholine under continuous ECG and coronary angiography monitoring.
Results and discussion. In patients with ischemia with non-obstructive coronary arteries (INOCA), the predominant mechanism was epicardial vasospasm, diagnosed in 59.5 % of cases. Endothelial dysfunction was detected in 26.2 % of patients, and isolated microvascular spasm in 14.3 %. The most frequent ECG marker of ischemia was T-wave inversion (59.5 %). The method proved to have a high safety profile: no life-threatening arrhythmias (VT/VF) were recorded. The observed complications (grade II–III AV blocks in 28.6 % of group A patients) were exclusively transient. Particular attention was paid to the «double hit» phenomenon – the combination of atherosclerosis and vasospasm, which significantly worsens the patient's prognosis.
Conclusions. The acetylcholine provocation test allows for precise endotyping of INOCA patients and personalization of therapy, including the prescription of calcium channel blockers for vasospasm and the mandatory discontinuation of non-selective beta-blockers to prevent undesirable vasoconstriction.
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