INOCA/MINOCA

Introduction to ANOCA and MINOCA

• Focus on heart disease in women

• Importance of understanding lesser-known conditions: ANOCA (Ischemia with Non-Obstructive Coronary Arteries) and MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries)

Historical Background

• Over two decades of research in women's heart disease

• Shift in knowledge: The need to rethink past assessments of coronary angiograms

• Early findings: 50% of women had normal coronary arteries vs 17% of men

• Issues with labeling women's stress tests as false positives

Clinical Implications

• The terminology of symptoms such as "atypical" needs revision

• Women have faced delays in treatment due to misunderstanding of their symptoms

• Consequences: Increased healthcare costs and major adverse cardiac events (MACE)

Definitions of ANOCA and MINOCA

• ANOCA: Ischemia with non-obstructive coronary arteries

• MINOCA: Myocardial infarction with non-obstructive coronary arteries, first coined in 2017 by Noel Beringeris

• Implications: Understanding that a significant proportion of ischemia in women is not due to obstructive disease (estimated at 50%)

• Importance of diagnosing correctly despite existing treatment limitations

Case Study: A 68-Year-Old Woman

• Symptoms: Recurrent chest pressure, lightheadedness, syncope

• Extensive evaluations: Normal coronary angiogram, misdiagnosed as vasovagal syncope

• Findings: Severe LAD and circumflex spasm; normal coronary flow reserve (CFR)

Ischemic Heart Disease Phenotypes

• Segmentation of ischemic heart disease into acute and chronic syndromes

• Distinction between obstructive and non-obstructive coronary disease

• Understanding functional ischemia: Coronary microvascular dysfunction and vasospasm

Diagnosis Challenges

• Difficulty in diagnosing functional ischemia due to the limitations of current tools

• Patients may feel dismissed and frustrated due to previous negative evaluations

• Importance of thorough evaluations to identify true conditions

Evaluation Pathway for Suspected ANOCA

• Initial evaluation steps include coronary CTA or functional tests depending on risk classification

• If symptoms persist, progression to coronary angiography is warranted

• Identifying non-obstructive disease varieties to confirm the diagnosis

Functional Angiogram and Its Role

• Role: Exclude epicardial vasospasm and assess microvascular functionality

• Functional mechanisms that indicate ischemia: Microvascular dysfunction vs structural mechanisms at the arterial level

• Investigating systemic factors contributing to microvascular dysfunction

Standard Functional Testing Protocols

• Use of agents like adenosine and acetylcholine in testing

• Identifying vasoconstriction in epicardial vessels through testing

• Adopting a stepwise approach in therapy based on diagnosis

Treatment Approaches

• Key treatments for microvascular dysfunction include:

  • Calcium channel blockers and nitrates for vasospasm

  • Beta blockers for structural concerns

  • Statins and lifestyle modifications

• Potential additional treatments include renal agents and dietary supplements

Understanding MINOCA

• Key factors for diagnosis: Elevated biomarkers aligned with ischemic symptoms

• Important causative factors: Plaque erosion, demand mismatch, syndromes like SCAD (Spontaneous Coronary Artery Dissection)

• Needing thorough investigation for underlying reasons contributing to MINOCA

Non-Ischemic Mimickers of Elevated Biomarkers

• Consideration of other conditions that may elevate troponins: Myocarditis, cardiac contusion, etc.

• Importance in accurately diagnosing the nature of the heart condition to guide treatment

Non-Invasive Imaging and Its Importance

• Use of imaging tools for reliable diagnosis and treatment strategy planning

• Early cardiac imaging, coronary CTA to look for atypical plaque characteristics

• Follow-up evaluations as necessary post-angiogram

Concluding Thoughts on Treatment Strategies

• Differentiating for treatment based on the underlying causes of symptoms

• Ensuring proper referral for cardiac rehabilitation to benefit psychosocial aspects of recovery

• Importance of continuous follow-up to ensure comprehensive care for women with ischemic heart disease conditions.