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)


Eur Heart J. 2019;40(29):2455-2462. 

In This Article

Knowledge Gaps

Patients with persistent or recurrent angina post-PCI present an unmet clinical need. Recent studies suggest that PCI may not be relied upon to improve angina.[2] The large International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) clinical trial is assessing the benefits of revascularization in addition to optimal medical therapy to improve health outcomes.[64] A recent study demonstrated that a simple non-invasive assessment of peripheral artery endothelial function during index PCI admission predicted the persistence or recurrence of angina/ischaemia at follow-up,[65] suggesting that assessment of endothelial dysfunction[66] may be useful for prediction of structural treatment benefit. We recognize that such tests are not feasible in daily practice, but the implication is that treatments which improve endothelial dysfunction may be beneficial. This possibility merits further prospective research.

In clinical practice, PCI for stable angina patients is currently a 'one-size-fits-all' approach, potentially useful for symptom relief in some symptomatic patients found to have epicardial obstructive CAD. In other patients, a significant epicardial stenosis may reflect more extensive vascular dysfunction, where PCI alone may be ineffective. We think more research is warranted into the prevalence and clinical significance of coronary vascular dysfunction in patients undergoing PCI.

When obstructive CAD is ruled out, post-PCI angina may be due to coronary vascular dysfunction caused by either increased IMR, epicardial or microvascular spasm, or both. In these circumstances, repeat PCI would be unlikely to be beneficial. An important knowledge gap is treatment of CMD.[67] Importantly, early evidence suggests that an empirical treatment of angina in the absence of obstructive coronary atherosclerosis guided by the assessment of functional coronary alterations is associated to a better outcome as compared to a strategy guided by angiography only.[61]

Finally, while current guidelines on percutaneous coronary revascularization do not fully address the issue of persistent/recurrent angina, it would be desirable to do so in the future.[68]