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Meta-Analysis
. 2022 Apr 5;11(7):e023207.
doi: 10.1161/JAHA.121.023207. Epub 2022 Mar 18.

Prevalence of Coronary Microvascular Disease and Coronary Vasospasm in Patients With Nonobstructive Coronary Artery Disease: Systematic Review and Meta-Analysis

Niya Mileva  1   2 , Sakura Nagumo  1   3 , Takuya Mizukami  3 , Jeroen Sonck  1   4 , Colin Berry  5 , Emanuele Gallinoro  1   6 , Giovanni Monizzi  1 , Alessandro Candreva  1 , Daniel Munhoz  1   7   4 , Dobrin Vassilev  2 , Martin Penicka  1 , Emanuele Barbato  1   4 , Bernard De Bruyne  1   8 , Carlos Collet  1
Affiliations
Meta-Analysis

Prevalence of Coronary Microvascular Disease and Coronary Vasospasm in Patients With Nonobstructive Coronary Artery Disease: Systematic Review and Meta-Analysis

Niya Mileva et al. J Am Heart Assoc. .

Abstract

Background A relevant proportion of patients with suspected coronary artery disease undergo invasive coronary angiography showing normal or nonobstructive coronary arteries. However, the prevalence of coronary microvascular disease (CMD) and coronary spasm in patients with nonobstructive coronary artery disease remains to be determined. The objective of this study was to determine the prevalence of coronary CMD and coronary vasospastic angina in patients with no obstructive coronary artery disease. Methods and Results A systematic review and meta-analysis of studies assessing the prevalence of CMD and vasospastic angina in patients with no obstructive coronary artery disease was performed. Random-effects models were used to determine the prevalence of these 2 disease entities. Fifty-six studies comprising 14 427 patients were included. The pooled prevalence of CMD was 0.41 (95% CI, 0.36-0.47), epicardial vasospasm 0.40 (95% CI, 0.34-0.46) and microvascular spasm 24% (95% CI, 0.21-0.28). The prevalence of combined CMD and vasospastic angina was 0.23 (95% CI, 0.17-0.31). Female patients had a higher risk of presenting with CMD compared with male patients (risk ratio, 1.45 [95% CI, 1.11-1.90]). CMD prevalence was similar when assessed using noninvasive or invasive diagnostic methods. Conclusions In patients with no obstructive coronary artery disease, approximately half of the cases were reported to have CMD and/or coronary spasm. CMD was more prevalent among female patients. Greater awareness among physicians of ischemia with no obstructive coronary arteries is urgently needed for accurate diagnosis and patient-tailored management.

Keywords: angina with nonobstructive coronary artery disease; ischemia with no obstructive coronary artery disease; vasospastic angina.

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Figures

Figure 1
Figure 1. Methods used for evaluation of microvascular disease.
A, Transthoracic echocardiography with Doppler of LAD. B, PET. C, MIBI SPECT. D, CMR. E, Doppler CFR. F, Absolute coronary blood flow measured by thermodilution. G, Thermodilution, CFR and IMR. H, Acetylcholine testing. CFR indicates coronary flow reserve; CMR, cardiac magnetic resonance; IMR, index of microcirculatory resistance. LAD, left anterior descending artery; MIBI SPECT, myocardial perfusion imaging on single photon emission computed tomography; and PET, positron emission tomography.
Figure 2
Figure 2. Preferred Reporting Items for Systematic Reviews and Meta‐Analyses flowchart.
CAD indicates coronary artery disease.
Figure 3
Figure 3. Bar plot chart with studies evaluating the prevalence of CMD assessed by invasive (different shades of red) and noninvasive (different shades of blue) methods.
Solid gray line illustrates the 42% pooled prevalence of CMD, and the dashed lines illustrate 95% CIs. CFR indicates invasive measurement of coronary flow reserve, Doppler, and thermodilution method; CMR, cardiac magnetic resonance; IMR, index of microcirculatory resistance; PET, positron emission tomography; and SPECT, myocardial perfusion imaging on single photon emission computed tomography.
Figure 4
Figure 4. Prevalence of coronary microvascular dysfunction.
The vertical black line indicates the pooled averaged prevalence rate estimate, and the red diamond represents the overall estimated prevalence with 95% CI in a random‐effects model. Gray squares indicate weighted‐point estimates of incidence for each single study, with gray horizontal lines indicating 95% CI. I 2 indicates Higgins index of heterogeneity. Pos indicates positive; and Tot, total.
Figure 5
Figure 5. Sensitivity analysis of prevalence of microvascular disease according to sex.
A, Forest plot illustrating the risk ratio (RR) and 95% CI of prevalence of coronary microvascular disease according to sex. B, Metaregression plot showing association between the prevalence of coronary microvascular resistance (y‐axis) and the proportion of women included in each study. The size of the bubble represents the number of patients included in each study. Neg indicates negative; and Pos, positive.
Figure 6
Figure 6. Prevalence of coronary vasospasm.
The vertical black line indicates the pooled averaged prevalence rate estimate, and the red diamond represents the overall estimated prevalence with 95% CI in a random‐effects model. Gray squares indicate weighted‐point estimates of incidence for each single study, with gray horizontal lines indicating 95% CI. I 2 indicates Higgins index of heterogeneity.
Figure 7
Figure 7. Prevalence of coronary microvascular spasm.
Figure 8
Figure 8. Sensitivity analysis of prevalence of coronary vasospasm according to sex.
A, Forest plot illustrating the risk ratio (RR) and 95% CI of the prevalence of coronary vasospasm according to sex. B, Metaregression plot showing association between the prevalence of coronary vasospasm (y‐axis) and the proportion of women included in each study. The size of the bubble represents the number of patients included in each study. Neg indicates negative; and Pos, positive.
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