Determinants of long-term clinical outcomes in patients with angina but without obstructive coronary artery disease: a systematic review and meta-analysis.

Aims: The long-term prognosis of angina in patients without obstructive coronary artery disease (CAD) is uncertain. To assess the incidence of long-term adverse outcomes in such patients. Methods and results: We searched PubMed, Cochrane Library, the Embase database, and the Clinical Trials Registry for studies published in English until January 2017, assessing the composite primary outcome of all-cause death and non-fatal myocardial infarction using random-effects models to estimate pooled incidences. We identified 54 studies, reporting outcomes in overall 35 039 patients (mean age 56, male/female ratio 0.51, 99 770 person-years) with angina and no obstructive CAD. After a median follow-up of 5 years (interquartile range 3-7 years), the pooled incidence of the primary outcome was 0.98/100 person-years [95% confidence interval (CI) 0.77-1.19%], with considerable heterogeneity among studies (I2 = 91%, P < 0.001). The primary outcome was associated with prevalent dyslipidaemia (P = 0.016), diabetes (P = 0.035), and hypertension (P = 0.016). Studies enrolling patients with less-than-obstructive CAD showed a higher incidence of the primary outcome (1.32/100 person-years, 95% CI 1.02-1.62) compared with studies including only patients with 'entirely normal' coronary arteries (0.52/100 person-years, 95% CI 0.34-0.79, respectively; P < 0.01). The incidence of the primary outcome did not differ significantly between studies enrolling only patients with documented myocardial ischaemia and those studies enrolling patients regardless of presence of ischaemia. However, ischaemia documented by non-invasive imaging techniques was associated with a higher incidence of events (P = 0.02). Overall, these patients, however, suffered from a high incidence of recurrent hospitalization. Conclusion: Angina without obstructive CAD has a heterogeneous prognosis. A main determinant of major adverse events is the presence of 'some' coronary atherosclerosis, with unequivocal myocardial ischaemia being associated with worse clinical outcomes. Patients' quality of life is also worsened by the high incidence of hospitalization, angina recurrence, and repeated coronary angiography.

[The healed plaque: tale of a story with good ending - with practical implications]. / La placca guarita: racconto di una storia a lieto fine, con implicazioni pratiche.

Acute coronary syndromes have heterogeneous clinical presentations, features and prognosis. They can also occur without angiographic evidence of significant coronary artery stenosis, based on multiple causes. We report on the diagnostic and therapeutic management of a 56-year-old man with an acute coronary syndrome and angiographic evidence of non-obstructive coronary artery disease. In addition to the basic angiographic evaluation, intracoronary imaging was here helpful to understand the underlying mechanism, prompting a tailored therapeutic strategy and avoiding inappropriate treatment with percutaneous coronary intervention and stenting. This clinical case here described offers the opportunity to briefly recapitulate the most meaningful milestones in the progress in the pathophysiology of acute coronary syndromes, also focusing on myocardial infarction non-obstructive coronary artery, and to appreciate the occurrence of rare cases and consequent lessons.

Calcific lesion preparation for coronary bifurcation stenting.

Bifurcating coronary lesions are a very common challenge in interventional cardiology because of the technical complexity in their treatment, the risk of side branch occlusion and an overall worse outcome when compared to non-bifurcating lesions. The presence of calcifications represents further complexity due to the difficulty in device delivery and stent expansion as well as enhanced risk of side branch occlusion. Rotational and orbital atherectomy, scoring and cutting balloons, coronary lithoplasty are available tools which have been introduced over the last three decades to overcome such issue. Nevertheless, their application in different contexts of bifurcations presents specific caveats and the studies directed at comparing such techniques have never been expressly oriented in the subset of the bifurcating lesion. In this paper, we review these devices and their usefulness in bifurcations by analyzing consistent data from clinical trials, and we propose a practical algorithm for the treatment of severely calcified bifurcating lesions according to their anatomical features.