Radico Francesco, Di Castelnuovo Augusto, Aimo Alberto, Zimarino Marco, Knuuti Juhani, Rossi Serena, Pastormerlo Luigi Emilio, Zyw Luc, Orsini Enrico, Iacoviello Licia, Neglia Danilo, Emdin Michele, de Gaetano Giovanni, De Caterina Raffaele
Institute of Cardiology, "G. d'Annunzio" University, Chieti, Italy.
ASL 2 Abruzzo, Chieti, Italy.
J Intern Med. 2022 Feb;291(2):197-206. doi: 10.1111/joim.13390. Epub 2021 Oct 6.
The absence of obstructive coronary artery disease (CAD) in patients with angina is common, but its prognosis is debated. We investigated outcomes of such patients to identify predictors of cardiovascular events.
We selected 1014 patients with angina, evidence of myocardial ischemia at the electrocardiogram (ECG) exercise test or imaging stress tests, and nonobstructive CAD (absence of lumen diameter reduction ≥50%) at coronary angiography between 1999 and 2015. Note that, 1905 age- and risk factors-matched asymptomatic subjects served as "real-world" comparators. The primary endpoint was the occurrence of all-cause death or myocardial infarction.
At 6-years median follow-up (interquartile range, 3-9 years), the primary endpoint occurred in 53 patients (5.5%, 0.92/100 person-years). Besides similar event rates compared with asymptomatic subjects (hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.62-1.15, p = 0.28), the index population showed a very heterogeneous prognosis. Patients with nonobstructive CAD (HR 1.85, 95% CI 1.02-3.37, p = 0.04, compared with "normal" coronary arteries) and ischemia at imaging tests (HR 2.11, 95% CI 1.07-4.14, p = 0.03, compared with ischemia detected only at the ECG exercise test) were at higher risk and those with both these components showing even >10-fold event rates as compared with the absence of both. Three-hundred and twenty-five patients (34%) continued to experience angina, 69 (7.2%) underwent repeat coronary angiography, and 14 (1.5%) had consequent coronary revascularization for atherosclerosis progression.
Apart from the impaired quality of life, angina without obstructive CAD has an overall benign but very heterogeneous prognosis. Nonobstructive CAD and myocardial ischemia at imaging tests both confer a higher risk.
心绞痛患者中无阻塞性冠状动脉疾病（CAD）的情况很常见，但其预后存在争议。我们研究了这类患者的预后情况，以确定心血管事件的预测因素。
我们选取了1014例心绞痛患者，这些患者在心电图（ECG）运动试验或影像学负荷试验中有心肌缺血证据，且在1999年至2015年期间冠状动脉造影显示无阻塞性CAD（管腔直径缩小≥50%）。请注意，1905例年龄和风险因素匹配的无症状受试者作为“真实世界”对照。主要终点是全因死亡或心肌梗死的发生。
在中位随访6年（四分位间距，3 - 9年）时，53例患者（5.5%，0.92/100人年）发生了主要终点事件。除了与无症状受试者相比事件发生率相似（风险比[HR] 0.85，95%置信区间[CI] 0.62 - 1.15，p = 0.28）外，该指数人群的预后非常不均一。与“正常”冠状动脉相比，无阻塞性CAD的患者（HR 1.85，95% CI 1.02 - 3.37，p = 0.04）以及影像学检查有缺血的患者（与仅在ECG运动试验中检测到缺血相比，HR 2.11，95% CI 1.07 - 4.14，p = 0.03）风险更高，同时具备这两个因素的患者与两者皆无的患者相比，事件发生率甚至高出10倍以上。325例患者（34%）继续有心绞痛症状，69例（7.2%）接受了重复冠状动脉造影，14例（1.5%）因动脉粥样硬化进展而接受了冠状动脉血运重建。
除生活质量受损外，无阻塞性CAD的心绞痛总体预后良好但非常不均一。无阻塞性CAD和影像学检查中的心肌缺血均会带来更高风险。
