RESUMO
Up to 65% of women and approximately 30% of men have ischemia with no obstructive coronary artery disease (CAD; commonly known as INOCA) on invasive coronary angiography performed for stable angina. INOCA can be due to coronary microvascular dysfunction or coronary vasospasm. Despite the absence of obstructive CAD, those with INOCA have an increased risk of all-cause mortality and adverse outcomes, including recurrent angina and cardiovascular events. These patients often undergo repeat testing, including cardiac catheterization, resulting in lifetime healthcare costs that rival those for obstructive CAD. Patients with INOCA often remain undiagnosed and untreated. This review discusses the symptoms and prognosis of INOCA, offers a systematic approach to the diagnostic evaluation of these patients, and summarizes therapeutic management, including tailored therapy according to underlying pathophysiological mechanisms.
Jusqu'à 65 % des femmes et environ 30 % des hommes présentent une ischémie sans coronaropathie obstructive (INOCA [ischemia with no obstructive coronary artery disease]) révélée à la faveur d'une angiographie coronarienne invasive réalisée pour une angine stable. L'INOCA peut être attribuable à une dysfonction microvasculaire coronaire ou à un vasospasme coronaire. Malgré l'absence de coronaropathie obstructive, les patients atteints d'une INOCA présentent un risque accru de décès toutes causes confondues et d'événements indésirables, notamment l'angine récurrente et des événements cardiovasculaires. Ces patients sont souvent soumis à des examens répétés, dont le cathétérisme cardiaque, ce qui représente des dépenses de santé à vie qui rivalisent avec celles associées aux coronaropathies obstructives. Dans bien des cas, l'INOCA échappe au diagnostic et n'est pas traité. Dans le présent article de synthèse, nous nous penchons sur les symptômes et le pronostic de l'INOCA. Nous proposons une méthode systématique d'évaluation diagnostique de ces patients et résumons les modalités de sa prise en charge thérapeutique, notamment un traitement adapté aux mécanismes physiopathologiques sous-jacents.
RESUMO
BACKGROUND: Optimal preprocedural planning is essential to ensure successful device closure of the left atrial appendage (LAA). DESIGN: The PREDICT-LAA study is a prospective, international, multicentre, randomised controlled trial (ClinicalTrials.gov NCT04180605). Two hundred patients eligible for LAA closure with an Amplatzer Amulet device (Abbott, USA) will be enrolled in the study. Patients will be allocated to a computational simulation arm (experimental) or standard treatment arm (control) using a 1:1 randomisation. For patients randomised to the computational simulation arm, preprocedural planning will be based on the analysis of cardiac computed tomography (CCT)-based patient-specific computational simulations (FEops HEARTguide, Ghent, Belgium) in order to predict optimal device size and position. For patients in the control arm, preprocedural planning will be based on local practice including CCT analysis. The LAA closure procedure and postprocedural antithrombotic therapy will follow local practice in both arms. The primary endpoint of the study is incomplete LAA closure and device-related thrombus as assessed at 3 months postprocedural CCT. Secondary endpoints encompass procedural efficiency (number of devices used, number of repositioning, procedural time, radiation exposure, contrast dye), procedure-related complications within 7 days postprocedure and a composite of all-cause death and thromboembolic events at 12 months. CONCLUSION: The objective of the PREDICT-LAA study is to test the hypothesis that a preprocedural planning for LAA closure with the Amplatzer Amulet device based on patient-specific computational simulations can result in a more efficient procedure, optimised procedural outcomes and better clinical outcomes as compared with a standard preprocedural planning. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT04180605).