Precision medicine in INOCA: real-world impact of invasive phenotyping on pharmacotherapy
J Harpula, A Cmiel, M Bujak, A Blach, W Wojakowski, P GasiorAbstract
Introduction
Management of Ischemia with No Obstructive Coronary Arteries (INOCA) remains largely empirical due to diagnostic uncertainty. We aimed to evaluate the clinical utility of comprehensive invasive coronary physiology in guiding precision pharmacotherapy and to explore the hemodynamic coupling between microvascular resistance and myocardial function in a prospective real-world registry.
Methods
We analyzed 43 consecutive patients (mean age 65.8±9.6 years) with stable angina and non-obstructive coronary arteries. A comprehensive invasive protocol, including Coronary Flow Reserve (CFR), Index of Microcirculatory Resistance (IMR), and Acetylcholine (ACh) provocation, was successfully completed in 39 patients. Therapeutic decisions were compared pre- and post-procedure. Additionally, the relationship between invasive indices and baseline echocardiographic parameters was assessed to identify early markers of ventricular impairment.
Results
Definitive invasive phenotyping identified a specific underlying pathology (Microvascular and/or Vasospastic Angina) in 71.8% of patients (28/39), with 11 patients had excluded impairment. The use of calcium channel blockers (CCB) increased from 40.5% to 78.4% (p<0.01), whereas empirical beta-blocker therapy was de-escalated from 91.4% to 45.7% (p<0.01). Anti-atherosclerotic therapy increased from 75% to 100% statin coverage and the use of RAAS inhibitors (ACE/ARB) increased from 69.4% to 80.6%. While all patients presented with preserved Left Ventricular Ejection Fraction (LVEF >50%), an inverse correlation was found between IMR and LVEF (Spearman's rho = -0.40, p<0.05). Standard diastolic parameters showed no linear correlation with IMR in this cohort.
Conclusions
Comprehensive invasive phenotyping is a necessary tool for implementing precision medicine in INOCA, driving significant optimization. Furthermore, the association between elevated IMR and lower LVEF suggests that increased microvascular resistance could contribute to subclinical myocardial dysfunction, yet this needs to be assessed in future studies.Central Illustration