myocardial ischemia without obstructive coronary stenoses

Conditions: Myocardial Ischemia; Non-Obstructive Coronary Atherosclerosis; Microvascular Coronary Artery Disease; Vasospastic Angina; Myocardial Bridging

Summary: coronary-related myocardial ischemia can result from obstructive epicardial stenosis or non-obstructive causes including coronary microcirculatory dysfunction and vasomotor disorders. this prospective study has been created in order to provide knowledge in the field of non-obstructive coronary artery disease.

all-comer patients referred for coronary physiological assessment with pressure-flow measurements and acetylcholine endothelial function test, aimed to investigate different aspects of non-obstructive coronary artery disease, will be enrolled. coronary hemodynamics during adenosine or acetylcholine evaluation will be measured either with a physiology wire equipped with pressure and temperature sensors (abbott), or with a physiology wire equipped with pressure sensor and doppler (philips). non-endothelium-dependent functional assessment will be performed with intravenous or intracoronary adenosine administration following the standard practice. endothelium-dependent functional assessment will be performed with intracoronary acetylcholine bolus administration following the standard practice, which includes continuous 12-lead ecg monitorization. microcirculatory dysfunction and vasomotor disorders will be diagnosed according to the criteria from the last european expert consensus on ischaemia with non-obstructive coronary arteries (inoca). medical therapy will be adjusted on the basis of physiology study results and patients will be followed at 30 days, 1-, 2- and 5-years either at the outpatient clinic or by telephone contact. the seattle questionnaire of angina will be applied during follow-up for obtaining an objective characterisation of the angina status. objectives of the study: * to investigate the coronary hemodynamics across the spectrum of coronary microcirculatory dysfunction. * to investigate the coronary hemodynamics across the spectrum of vasomotor disorders. * to investigate the impact of coronary microcirculatory dysfunction on clinical outcomes and patient symptoms at long-term follow-up. * to investigate the impact of coronary vasomotor disorders on clinical outcomes and patient symptoms at long-term follow-up. * to investigate the impact of a stratified medical therapy (guided by invasive physiology study) on patient symptoms. * to investigate the role of microcirculatory dysfunction and vasomotor disorders in different settings of ischemic heart disease (i.e., recurrent angina despite successful percutaneous coronary intervention; myocardial infarction without obstructive coronary artery disease; left ventricular dysfunction (either systolic or diastolic) with or without heart failure). * to develop new, alternative methods aimed to assess the coronary microcirculation. * to investigate the role of myocardial bridging on myocardial ischemia generating mechanisms. * to document safety of intracoronary testing in routine clinical practice.

Eligibility criteria:
inclusion criteria: * written informed consent available. * age ≥ 18 years. * patient eligible for invasive physiological assessment with adenosine and / or acetylcholine. exclusion criteria: * hemodynamic instability. * anticipated technical issues for physiology wire measurements. * culprit vessel of acute coronary syndrome * contraindications for adenosine administration. * contraindications for acetylcholine test. * reduced life expectancy (less than 1 year).