Mechanisms and Diagnostic Evaluation of Persistent or Recurrent Angina Following Percutaneous Coronary Revascularization

Filippo Crea; Cathleen Noel Bairey Merz; John F. Beltrame; Colin Berry; Paolo G. Camici; Juan Carlos Kaski; Peter Ong; Carl J. Pepine; Udo Sechtem; Hiroaki Shimokawa; On behalf of the Coronary Vasomotion Disorders International Study Group (COVADIS)

Disclosures

Eur Heart J. 2019;40(29):2455-2462. 

In This Article

Abstract and Introduction

Abstract

Persistence or recurrence of angina after a percutaneous coronary intervention (PCI) may affect about 20–40% of patients during short–medium-term follow-up. This appears to be true even when PCI is 'optimized' using physiology-guided approaches and drug-eluting stents. Importantly, persistent or recurrent angina post-PCI is associated with a significant economic burden. Healthcare costs may be almost two-fold higher among patients with persistent or recurrent angina post-PCI vs. those who become symptom-free. However, practice guideline recommendations regarding the management of patients with angina post-PCI are unclear. Gaps in evidence into the mechanisms of post-PCI angina are relevant, and more research seems warranted. The purpose of this document is to review potential mechanisms for the persistence or recurrence of angina post-PCI, propose a practical diagnostic algorithm, and summarize current knowledge gaps.

Introduction

Procedural success is routinely achieved in patients with obstructive coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). In the current European Society of Cardiology guidelines on stable obstructive CAD, coronary revascularization has a Class 1, Level A recommendation on prognostic grounds for patients with left main stem disease or multivessel CAD, and also for symptoms in the presence of limiting angina or angina-equivalent, unresponsive to optimal medical therapy.[1] Persistence or recurrence of angina after PCI is well recognized and may affect about 20–40% of patients during short–medium-term follow-up.[2–7] This appears to be true even when PCI is 'optimized' using physiology-guided approaches [e.g. fractional flow reserve (FFR) or non-hyperaemic pressure ratio (NHPR)][8] and drug-eluting stents (DES) or stents with bioresorbable scaffolds.[9] Importantly, persistent or recurrent angina post-PCI is associated with a significant economic burden. Healthcare costs may be almost two-fold higher among patients with persistent or recurrent angina post-PCI vs. those who become symptom-free.[10] Furthermore, the role of PCI for symptom relief, when added to optimal medical therapy, remains a controversial issue.[11–14] In the ORBITA trial, the benefits of PCI compared with a 'sham control' placebo were unclear. One potential mechanism for persistent angina post-PCI identified by the investigators was microvascular angina,[2] although this trial has been criticized because of methodological limitations.[15]

The clinical importance of angina recurrence following successful PCI is evident from developments in clinical quality registries, where post-PCI angina is being utilized as a clinical performance marker for PCI.[16] Despite this, while prospective studies have documented that angina, including with inducible ischaemia, is a contributing factor in many patients with chest discomfort symptoms post-PCI,[17] few studies have systematically addressed the mechanisms responsible for the recurrent angina[18,19] and there are no comprehensive recommendations for its diagnosis or treatment.[1,20]

The purpose of this document, which expands and gives a global perspective to what we have previously published,[3] is to review potential mechanisms for the persistence or recurrence of angina post-PCI, propose a practical diagnostic algorithm, and summarize current knowledge gaps.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....