Ишемия миокарда без обструкции коронарных артерий (INOCA). Часть II. Клинико-инструментальные особенности патологии

Вопросы диагностики, ведения и лечения больных с ишемией без обструкции коронарных артерий (INOCA) остаются до конца не решенными, особенно в условиях реальной клинической практики. Целью ретроспективного наблюдательного исследования был анализ клиникоинструментальных особенностей пациентов с INOCA, с попыткой выделить наиболее вероятные патогенетические варианты заболевания для дальнейшей высокотехнологичной диагностики и разработки индивидуальной тактики лечения. Проанализированы 52 истории болезни пациентов с INOCA, госпитализированных в НИИ СП им. Н.В. Склифосовского с диагнозом «острый коронарный синдром без подъема сегмента ST», у которых по данным коронарографии (КАГ) не было выявлено стенозов коронарных артерий (КА) либо сужения были менее 50%. По данным КАГ, у 41 пациента (78,8%) выявлены аномалии КА (мышечный миокардиальный мостик, патологическая извитость, замедление пассажа контраста, спазм). Перенесенный ранее инфаркт миокарда диагностирован у 42,3% больных. Пациенты распределены по предполагаемым эндотипам INOCA, среди которых чаще встречался вазоспастический вариант. В условиях кардиологического стационара врачу необходимо своевременно и в полном объеме оценить клинико-инструментальную характеристику пациента с INOCA для определения показаний к проведению специализированной внутрикоронарной диагностики, атакже назначению оптимальной комплексной терапии, включая рентгенэндоваскулярные и хирургические методы.

1. Shah SM, Tremmel JA, Henry TD, Smilowitz NR, Prasad M, Kobayashi Y, Henry GA, Samady H, Samuels BA, Lerman A, Moses JW, Pietras C, Zhang Z, Tirziu D, Parise H, Cristea E, Chamié D, Grubman D, Henrici K, Matmusaeva E, Latif N, Cigarroa N, Lansky AJ. Determining the Cause of Coronary Vasomotor Disorders in Patients with Ischemia and Nonobstructive Coronary Arteries: Design and Rationale of the DISCOVER INOCA Prospective, Multicenter Registry. J Soc Cardiovasc Angiogr Interv. 2024; 3 (6): 102046. https://doi.org/10.1016/j.jscai.2024.102046

2. Odanović N, Schwann AN, Zhang Z, Kapadia SS, Kunnirickal SJ, Parise H, et al. Long-term outcomes of ischaemia with no obstructive coronary artery disease (INOCA): a systematic review and meta-analysis. Open Heart. 2024; 11 (2): e002852. https://doi.org/10.1136/openhrt‑2024-002852

3. Ya’qoub L, Elgendy IY, Pepine CJ. Syndrome of Nonobstructive Coronary Artery Diseases: A Comprehensive Overview of Open Artery Ischemia. Am J Med. 2021; 134 (11): 1321–1329. https://doi.org/10.1016/j.amjmed.2021.06.038

4. Gulati M, Khan N, George M, Berry C, Chieffo A, Camici PG. et al. Ischemia with no obstructive coronary artery disease (INOCA): A patient self-report quality of life survey from INOCA international. Int J Cardiol. 2023; 371: 28–39. https://doi.org/10.1016/j.ijcard.2022.09.047

5. Boden WE, Marzilli M, Crea F, Mancini GBJ, Weintraub WS, Taqueti VR. et al.; Chronic Myocardial Ischemic Syndromes Task Force. Evolving management paradigm for stable ischemic heart disease patients: JACC Review Topic of the Week J Am Coll Cardiol. 2023; 81 (5): 505–514. https://doi.org/10.1016/j.jacc.2022.08.814

6. Barbarash O.L., Karpov Yu.A., Panov A.V., Akchurin R.S., Alekyan B.G., Alekhin M.N., Aronov D.M., Harutyunyan G.K., Belenkov Yu.N., Boytsov S.A., Boldueva S.A., Boschenko A.A., Bubnova M.G., Bulkina O. S., Vasyuk Yu.A., Galyavich A. S., Glezer M.G., Golubev E.P., Golukhova E.Z., Grinstein Yu.I., Davidovich I.M., Yezhov M.V., Zavadovsky K.V., Irtyuga O.B., Karpov R.S., Koziolova V.V., Koziolova N.A., Korennova O. Yu., Kosmacheva E.D., Koshelskaya O.A., Kukharchuk V.V., Lopatin Yu.M., Merkulov E.V., Mironov V.M., Martsevich S. Yu., Mirolyubova O.A., Mikhin V.P., Nedoshivin A.O., Nikulina N.N., Nikulina S. Yu., Oleinikov V.E., Panchenko E.P., Perepech N.B., Petrova M.M., Protasov K.V., Saidova M.A., Samko A.N., Sergienko I.V., Sinitsyn V. E., Skibitsky V.V., Soboleva G.N., Shalaev S.V., Shaposhnik I.I., Shevchenko A.O., Shiryaev A.A., Shlyakhto E.V., Chumakova G.A., Yakushin S. S. 2024 Clinical practice guidelines for Stable coronary artery disease. Russian Journal of Cardiology. 2024;29(9):6110. (In Russ.) https://doi.org/10.15829/1560‑4071‑2024‑6110. EDN: HHJJUT

7. Pasupathy S, Lindahl B, Litwin P, Tavella R, Williams MJA, Air T, et al. Survival in Patients with Suspected Myocardial Infarction with Nonobstructive Coronary Arteries: A Comprehensive Systematic Review and Meta-Analysis from the MINOCA Global Collaboration. Circ Cardiovasc Qual Outcomes. 2021; 14 (11): e007880. https://doi.org/10.1161/CIRCOUTCOMES.121.007880

8. Figura E, Zaremba M, Rogula S, Rolek B, Gasecka A, Kołtowski Ł. Coronary slow flow and microvascular spasm as an underrecognized cause of chest pain. Postepy Kardiol Interwencyjnej. 2023; 19 (3): 289–291. https://doi.org/10.5114/aic.2023.131484

9. Kunadian V, Chieffo A, Camici PG, Berry C, Escaned J, Maas AHEM, et al. An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. Eur Heart J. 2020; 41 (37): 3504–3520. https://doi.org/10.1093/eurheartj/ehaa503

10. Patel N, Greene N, Guynn N, Sharma A, Toleva O, Mehta PK. Ischemia but no obstructive coronary artery disease: more than meets the eye. Climacteric. 2023; 27 (1): 22–31. https://doi.org/10.1080/13697137.2023.2281933

11. Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, et al.; ESC Scientific Document Group. 2024 ESC Guidelines for the management of chronic coronary syndromes: Developed by the task force for the management of chronic coronary syndromes of the European Society of Cardiology (ESC) Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024; 45 (36): 3415–3537. https://doi.org/10.1093/eurheartj/ehae177

12. Hansen B, Holtzman JN, Juszczynski C, Khan N, Kaur G, Varma B, Ischemia with No Obstructive Arteries (INOCA): A Review of the Prevalence, Diagnosis and Management. Curr Probl Cardiol. 2023; 48 (1): 101420. https://doi.org/10.1016/j.cpcardiol.2022.101420

13. van Schalkwijk DL, Widdershoven J, Magro M, Smaardijk V, Bekendam M, Vermeltfoort I. et al. Clinical and psychological characteristics of patients with ischemia and non-obstructive coronary arteries (INOCA) and obstructive coronary artery disease. Am Heart J Plus. 2023; 27: 100282. https://doi.org/10.1016/j.ahjo.2023.100282

14. Park J, Kim HL, Kim MA, Kim M, Park SM, Yoon HJ. et al. Traditional Cardiovascular Risk Factors and Obstructive Coronary Disease in Patients with Stable Chest Pain: Gender-specific Analysis. Cardiometab Syndr J. 2021; 1 (1): 101–110. https://doi.org/10.51789/cmsj.2021.1.e7

15. Qi L, Qu X, Shi K, Mao D, Li M. Increased Epicardial Fat Tissue is Predictor for Patients with Ischemia and No Obstructive Coronary Artery Disease. IJ Radiol. 2020; 17 (4): e102083. https://doi.org/10.5812/iranjradiol.102083

16. Polyak A, Wei J, Gulati M, Merz NB.Clinical aspects of ischemia with no obstructive coronary artery disease (INOCA). Am Heart J Plus. 2024; 37: 100352. https://doi.org/10.1016/j.ahjo.2023.100352

17. Jalali Z, Khademalhosseini M, Soltani N, Esmaeili Nadimi A. Smoking, alcohol and opioids effect on coronary microcirculation: an update overview. BMC Cardiovasc Disord. 2021; 21 (1): 185. https://doi.org/10.1186/s12872-021-01990-y

18. Zhang H, Che W, Shi K, Huang Y, Xu C, Fei M, et al. FT4/FT3 ratio: A novel biomarker predicts coronary microvascular dysfunction (CMD) in euthyroid INOCA patients. Front Endocrinol (Lausanne). 2022; 13: 1021326. https://doi.org/10.3389/fendo.2022.1021326

19. Aldiwani H, Mahdai S, Alhatemi G, Bairey Merz CN. Microvascular Angina: Diagnosis and Management. Eur Cardiol. 2021; 16: e46. https://doi.org/10.15420/ecr.2021.15 eCollection 2021 Feb.

20. de Luna AB, Cygankiewicz I, Baranchuk A, Fiol M, Birnbaum Y, Nikus K, et al. Prinzmetal angina: ECG changes and clinical considerations: a consensus paper. Ann Noninvasive Electrocardiol. 2014; 19 (5): 442–453. https://doi.org/10.1111/anec.12194

21. Sternheim D, Power DA, Samtani R, Kini A, Fuster V, Sharma S. Myocardial Bridging: Diagnosis, Functional Assessment, and Management: JACC State-of-the-Art Review. J Am Coll Cardiol. 2021; 78 (22): 2196–2212. https://doi.org/10.1016/j.jacc.2021.09.859

22. Teragawa H, Oshita C, Uchimura Y. The Impact of Myocardial Bridging on the Coronary Functional Test in Patients with Ischaemia with Non-Obstructive Coronary Artery Disease. Life (Basel). 2022; 12 (10): 1560. https://doi.org/10.3390/life12101560

23. Sinha A, Rahman H, Rajani R, Demir OM, Li KamWa M, Morgan H, et al. Characterizing Mechanisms of Ischemia in Patients with Myocardial Bridges. Circ Cardiovasc Interv. 2024; 17 (1): e013657. https://doi.org/10.1161/CIRCINTERVENTIONS.123.013657

24. Pargaonkar VS, Kimura T, Kameda R, Tanaka S, Yamada R, Schwartz JG, et al. Invasive assessment of myocardial bridging in patients with angina and no obstructive coronary artery disease. EuroIntervention. 2021; 16 (13): 1070–1078. https://doi.org/10.4244/EIJ-D‑20–00779

25. Hostiuc S, Rusu MC, Hostiuc M, Negoi RI, Negoi I. Cardiovascular consequences of myocardial bridging: A meta-analysis and meta-regression. Sci Rep. 2017; 7 (1): 14644. https://doi.org/10.1038/s41598‑017‑13958‑0

26. Almeida AG. MINOCA and INOCA: Role in Heart Failure. Curr Heart Fail Rep. 2023; 20 (3): 139–150. https://doi.org/10.1007/s11897‑023‑00605‑1

27. Korjian S, Gibson C. Flowing Beyond Conventions: Rethinking Coronary Slow Flow in the Diagnosis of Microvascular Dysfunction. J Am Coll Cardiol Intv. 2024; 17 (7): 930–932. https://doi.org/10.1016/j.jcin.2024.02.006

28. Mayer M, Allan T, Harkin KL, Loftspring E, Saffari SE, Reynolds HR, et al. Angiographic Coronary Slow Flow Is Not a Valid Surrogate for Invasively Diagnosed Coronary Microvascular Dysfunction. JACC Cardiovasc Interv. 2024; 17 (7): 920–929. https://doi.org/10.1016/j.jcin.2024.02.025

29. Mihai DE, Delcea C, Buzea CA, Balan S, Dan GA. Coronary artery tortuosity and mid-term all-cause mortality of patients with ischemia and non-obstructive coronary arteries. Rom J Intern Med. 2023; 61 (4): 202–211. https://doi.org/10.2478/rjim‑2023-0019

30. Sohal S, Cristea E, Higney J, Williams O, Ohadi L, Samuels B. et al. TCT‑671 Evaluation of Coronary Tortuosity in Patients with Ischemia and No Coronary Artery Disease: Insights from the DISCOVER INOCA Multicenter Registry. J Am Coll Cardiol JACC. 2024; 84 (18, Suppl): B258. https://doi.org/10.1016/j.jacc.2024.09.796

31. Estrada A, Sousa AS, Mesquita CT, Villacorta H. Coronary Tortuosity as a New Phenotype for Ischemia without Coronary Artery Disease. Arq Bras Cardiol. 2022; 119 (6): 883–890. https://doi.org/10.36660/abc.20210787

32. Schumann CL, Mathew RC, Dean JL, Yang Y, Balfour PC Jr, Shaw PW. et al. Functional and economic impact of INOCA and influence of coronary microvascular dysfunction JACC Cardiovasc. Imaging. 2021; 14 (7): 1369–1379. https://doi.org/10.1016/j.jcmg.2021.01.041