Invasive Coronary Function Testing in Patients With Prior PCI Who Have Persistent ANOCA

Abstract

Background: Patients with post-percutaneous coronary intervention (PCI) angina are challenging to manage. Comprehensive coronary function testing (CFT) can identify occult coronary abnormalities in patients with angina and nonobstructive coronary arteries. Its utility in patients with post-PCI persistent angina who have no obstructive coronary artery disease is unexplored.

Methods: We assessed 46 patients with a prior PCI experiencing persistent angina. CFT evaluated the presence of endothelial dysfunction, epicardial and microvascular spasm, low fractional flow reserve, coronary microvascular dysfunction, and myocardial bridging by intravascular ultrasound. The Seattle Angina Questionnaire measured symptom severity before and 1-year post-CFT.

Results: The median age was 60 (53-69) years, with 63% being women. Pre-PCI lesion stenosis was 80 (70-90)% and pre-PCI fractional flow reserve (n=7) was 0.72 (0.67-0.74). Left anterior descending artery PCI was performed in 47.8%. The median duration between PCI and CFT was 19.5 (11.2-57.2) months. Patients reported severe anginal symptoms and poor quality of life on the Seattle Angina Questionnaire. CFT revealed a median fractional flow reserve of 0.84 (0.82-0.87), and 19.6% had a fractional flow reserve ≤0.8. Endothelial dysfunction was diagnosed in 36.9%, of whom 64.7% had moderate to severe endothelial dysfunction. Epicardial and microvascular spasm were present in 56.5% and 17.4%, respectively. Coronary microvascular dysfunction was present in 43.5%, and 63% had myocardial bridging. Patients reported significant improvement in Seattle Angina Questionnaire scores 1-year post-CFT.

Conclusions: Patients with post-PCI persistent angina have severe symptoms and poor quality of life, with the majority exhibiting endothelial dysfunction, epicardial spasm, coronary microvascular dysfunction, and myocardial bridging. Comprehensive CFT should be considered in these patients to help diagnose an underlying cause of their persistent angina and guide therapy for a better outcome.

Keywords: angina pectoris; humans; myocardial bridging; percutaneous coronary intervention; quality of life.