Chest pain, stress tests warrant attention even if arteries are clear

March 30, 2020

Patients who experience chest pain and have abnormal results on a cardiac stress test but who do not have blocked arteries often experience changes in their symptoms and stress test results over time, according to research presented at the American College of Cardiology's Annual Scientific Session Together with World Congress of Cardiology (ACC.20/WCC).

"Even though these patients had very abnormal stress test results, symptoms and stress test findings often changed over time, and the change in the stress test and the change in the symptoms did not necessarily go together," said Harmony R. Reynolds, MD, director of the Sarah Ross Soter Center for Women's Cardiovascular Disease at NYU Langone Health, New York and the study's lead author. "The results suggest the disease activity ebbs and flows--there may be periods of time when symptoms are more active and times when they are absent."

The study, called CIAO, enrolled 208 people who were screened for the ISCHEMIA trial but did not have a blockage of more than 50% on a coronary angiogram, making them ineligible for the large international trial. ISCHEMIA assessed treatments for coronary artery disease (CAD), a buildup of plaque in the heart's arteries.

The problem of blood flow limitation or heart symptoms in the absence of 50% or more artery narrowing is known as ischemia with no obstructive CAD, commonly referred to as INOCA. All patients had experienced chest pain or other heart-related symptoms (angina) and had abnormal results on a stress echocardiogram, a test in which a doctor uses ultrasound to image the heart before and after a patient exercises on a treadmill or stationary bike.

The researchers assessed participants' symptoms and stress test results at one year and compared CIAO patients' baseline findings to those of 1,079 patients who were enrolled in ISCHEMIA and had the same type of stress test used in CIAO, a stress echocardiogram. At baseline, they found that patients in CIAO and ISCHEMIA had similar amounts of ischemia on their stress tests despite patients not having obstructive CAD in CIAO. CIAO participants with INOCA had more frequent angina; 17% of these patients had angina weekly or more often, compared to 4% among those in ISCHEMIA with CAD. CIAO patients were also more likely to have angina in the last month; 41% of CIAO patients with INOCA reported no angina in the last month compared to 62% of ISCHEMIA patients with CAD.

At one year, half of CIAO patients' stress echocardiograms became normal and 45% were the same as at baseline or worse. Angina symptoms improved in 42% and worsened in 14% and the number of medications to control angina on average remained the same. The change in stress test findings over one year and the change in symptoms over one year were not related to one another.

One notable difference from the ISCHEMIA trial was that 66% of patients enrolled in CIAO were female, a much larger proportion than in ISCHEMIA, in which only 26% of enrolled patients were female. That finding fits with previous studies that have found women are more likely to experience chest pain symptoms and have abnormal stress test results than men despite showing less extensive plaque buildup in the arteries.

"This could relate to fundamental differences in how heart disease develops in women and men," Reynolds said. For example, prior studies have suggested women are more likely to experience small vessel disease, in which the smaller blood vessels restrict blood flow to the heart even if the main arteries are clear.

"The worry is that patients with INOCA will get the brush-off from doctors, who might believe patients are fine because their arteries are open," Reynolds said. "However, they cannot be ignored. Prior studies show that these patients are at higher risk than people without angina, although they are generally at lower risk than those with obstructive CAD."

In addition to small vessel disease, intermittent chest pain and ischemia could be caused by episodes of muscle spasms in the coronary arteries, Reynolds said. Further research is needed to determine the factors that contribute to such symptoms in the absence of CAD and determine appropriate treatment approaches, she said. The researchers plan to compare different heart disease assessment strategies to clarify how less invasive tests can be used to identify patients at higher risk.
-end-
The study was funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health.

ACC.20/WCC will take place March 28-30, bringing together cardiologists and cardiovascular specialists from around the world to share the newest discoveries in treatment and prevention. Follow @ACCinTouch, @ACCMediaCenter and #ACC20/#WCCardio for the latest news from the meeting.

The American College of Cardiology envisions a world where innovation and knowledge optimize cardiovascular care and outcomes. As the professional home for the entire cardiovascular care team, the mission of the College and its 54,000 members is to transform cardiovascular care and to improve heart health. The ACC bestows credentials upon cardiovascular professionals who meet stringent qualifications and leads in the formation of health policy, standards and guidelines. The College also provides professional medical education, disseminates cardiovascular research through its world-renowned JACC Journals, operates national registries to measure and improve care and offers cardiovascular accreditation to hospitals and institutions. For more, visit acc.org.

American College of Cardiology

Related Angina Articles from Brightsurf:

Angina drug fails to improve outcomes after successful revascularisation
Trimetazidine administered after successful percutaneous coronary intervention (PCI) does not improve outcomes in patients with chronic or acute coronary syndromes, according to results of the ATPCI trial presented in a Hot Line session today at ESC Congress 2020.

Nutritional screening a potential tool for determining heart attack, angina prognosis
In a study published today in the Journal of the American College of Cardiology of more than 5,000 acute coronary syndromes (ACS) patients, 71.8% were considered malnourished by at least one nutrition screening test, and worsening malnutrition status was associated with higher mortality and major adverse cardiovascular events (MACE), such as another heart attack or stroke.

Cell therapy treatment for cardiac patients with microvascular dysfunction provides enhanced quality
Trial results presented today revealed a promising therapy for patients experiencing angina due to coronary microvascular dysfunction (CMD).

Clinical trial in China on acupuncture as added treatment for chronic stable angina
This randomized clinical trial with about 400 adults conducted in China investigated acupuncture as an added treatment to antianginal therapies in reducing the frequency of angina attacks in patients with chronic stable angina.

Simple scan could direct treatments for angina
A 40 minute test for angina could help patients avoid an overnight stay in hospital, according to research funded by the NIHR Guy's and St Thomas' Biomedical Research Centre.

Cognitive decline may accelerate after heart attack, angina
Adults with incident coronary heart disease (CHD) are at higher risk for faster cognitive decline in the long-term, according to a study published today in the Journal of the American College of Cardiology.

Epidemiology, pathophysiology, and therapeutic targets in stable ischemic heart disease
In the current issue of Cardiovascular Innovations and Applications, C.

Henry Ford Hospital patient is first in the US to receive angina device
Cardiologists at Henry Ford Hospital performed the first implantation in the United States of a device approved for use in Europe for hard-to-treat angina.

Statins may bring benefits at time of treatment for heart attack, angina
Getting a large dose of a statin did not have an impact on major adverse cardiac events among a broad population of patients slated to undergo percutaneous coronary intervention (PCI), a procedure to clear blocked arteries, in a trial being presented at the American College of Cardiology's 67th Annual Scientific Session.

Study of heart stents for stable angina highlights potential of placebo effect
Researchers at Imperial College London have explored the placebo effects of a coronary angioplasty procedure with stents for the first time.

Read More: Angina News and Angina Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.