The patient journey in chronic coronary syndromes with/without obstructive coronary arteries

Background and aims: In patients undergoing invasive coronary angiography for the investigation of angina, the management pathways for obstructive coronary artery disease (CAD) are well described, whereas the clinical and diagnostic journey of patients with Angina with Non-Obstructive Coronary Arteries (ANOCA) has largely been inferred, as there is limited quantitative data. To compare the journey of patients with ANOCA vs. obstructive CAD, particularly in relation to (i) clinical presentation, and (ii) diagnostic assessment, (iii) 12 month patient-reported outcome measures, and (iv) 3-year composite major adverse cardiovascular events. 

Methods and results: A total of 2285 ANOCA and 4087 obstructive CAD consecutive patients were included from the CADOSA (Coronary Angiogram Database of South Australia) registry between 2012 and 2018. At presentation for elective invasive angiography, the chest pain features and non-invasive ischaemic markers were indistinguishable between patients with obstructive CAD and ANOCA, although the latter were younger (67 ± 11 vs. 61 ± 11 years, P < 0.001), more likely to be female (27 vs. 58%, P < 0.001) and have fewer traditional cardiac risk factors. However, following angiography (compared to those with obstructive CAD), patients with ANOCA were less likely to attain a cardiac discharge diagnosis (100 vs. 22%) or receive anti-anginal therapy (76 vs. 57%), despite the same prevalence of persistent angina (weekly angina: 10 vs. 11% over 12 months). 

Conclusion: Although the pre-angiography journey (symptoms and non-invasive ischaemic investigations) of patients with obstructive CAD and ANOCA is indistinguishable, the post-angiography journey is portrayed by a vast diagnostic and treatment gap in those with ANOCA, which needs to be addressed.