The functional assessment of patients with non-obstructive coronary artery disease: expert review from an international microcirculation working group

EuroIntervention 2019;14:1694-1702 published online December 2018. DOI: 10.4244/EIJ-D-18-00982

Robert J. Widmer
R. Jay Widmer1, MD, PhD; Bruce Samuels2, MD; Habib Samady3, MD; Matthew J. Price4, MD; Allen Jeremias5, MD; R. David Anderson6, MD; Farouc A. Jaffer7, MD, PhD; Javier Escaned8, MD, PhD; Justin Davies9, MBBS, PhD; Megha Prasad1, MD; Cindy Grines10, MD; Amir Lerman1*, MD
1. Mayo Clinic Department of Cardiovascular Medicine, Rochester, MN, USA; 2. Cedars-Sinai Heart Institute, Los Angeles, CA, USA; 3. Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; 4. Department of Cardiology, Scripps Translational Science Institute, La Jolla, CA, USA; 5. Division of Cardiovascular Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA; 6. Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA; 7. Cardiology Division, Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; 8. Hospital San Carlos, Madrid, Spain; 9. Royal Brompton Hospital, Imperial College London, London, United Kingdom; 10. North Shore University Hospital, Manhasset, NY, and Zucker Hofstra Northwell School of Medicine, Hempstead, NY, USA

Symptomatic non-obstructive coronary artery disease (NOCAD) is an increasingly recognised entity that is associated with poor cardiovascular outcomes. Nearly half of those undergoing coronary angiography for appropriate indications, such as typical angina, or a positive stress test have no obstructive lesion. There are no guideline recommendations as to how to care properly for these patients. Physiologic assessment of the coronary arteries beyond two-dimensional angiography is not standardised, yet it can provide valuable information in patients presenting with typical angina in the setting of NOCAD. In this consensus document, we detail steps for the interventional cardiologist to evaluate the patient with symptomatic NOCAD in the cardiac catheterisation laboratory, first with the assessment of coronary flow reserve (CFR), and then with delineation of deficiencies in non-endothelium-dependent CFR (CFRne) versus endothelium-dependent CFR (CFRe) using provocative agents such as adenosine and acetylcholine, respectively, followed by the evaluation of smooth muscle function with nitroglycerine (NTG). Once the mechanism behind the anginal symptoms is established, one can identify the appropriate treatment strategies to address the physiologic deficiency that is present. Despite an established safety profile, a comprehensive assessment may be considered for selected patients which requires an understanding of the appropriate invasive evaluation by the practising interventional cardiologist when evaluating not only patients with obstructive CAD but also those with NOCAD.

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coronary interventionsfractional flow reservemiscellaneousstable angina
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