Impact of coronary artery disease phenotype on treatment in chronic coronary syndromes: the EURECA registry
Authors: Liga R , Gimelli A , Podlesnikar P , Sredojevic M , Pontone G , Miglioranza M H , Sumin A , Saraste A , Sia C H , Sade L E , Maroz-Vadalazhskaya N , Knuuti J , Popescu B A , Delgado V , Neglia D 
Published: November 2023

Abstract

Background
The EURECA registry aimed to assess the use of stress ECG and cardiac imaging in the diagnostic process of patients with chronic coronary syndrome (CCS). To which extent the coronary artery disease (CAD) phenotype, defined by the diagnostic process, may influence the management of these patients in clinical practice is not known.

Purpose
In the present analysis we aimed to evaluate the impact of the CAD phenotype on downstream therapeutic choices in the EURECA population.

Methods
Among the 5156 patients enrolled in the EURECA registry between May 2019 and March 2020, early treatment choices (within 6 months from enrolment) could be defined in 4874 patients (mean age 63.5 years, 59.7% males). They were categorized as: 1. no treatment change; 2. optimized medical treatment (OMT, i.e. new therapy or increase of previous therapy); 3. revascularization. The CAD phenotypes were defined in 3771 patients as: 1. no CAD; 2. non-obstructive CAD; 3. obstructive CAD without documented ischemia (including patients with no stress test performed); 4. obstructive CAD with documented ischemia.

Results
In 3049/4874 patients (63%) treatment was unchanged, in 1204 (24%) medical treatment was optimized and in 621 patients (13%) revascularization was performed. At the end of the diagnostic process, the disease phenotype was no CAD in 1409/3771 patients (37%), non-obstructive CAD in 1463 (39%), obstructive CAD without documented ischemia in 374 (10%) and obstructive CAD with documented ischemia in 525 patients (14%). In patients with non-obstructive CAD, medical treatment was optimized more frequently than in those with no CAD (34% vs 19%, P&lt;0.001) but in 65% of these patients treatment was unchanged. In patients with obstructive CAD revascularization frequency was similar in patients without or with documented ischemia (60% vs 61%, P=NS) as well as OMT alone (21% and 18%, P=NS) (Figure 1). Revascularization or OMT alone were associated with enrolment in cardiology departments, older age, male gender, typical symptoms, higher frequency of risk factors, history of previous CAD and positive results of any non-invasive test (Figure 2). At multivariate analysis independent predictors of more intense treatment were enrolment in cardiology department (OR 1.55, 95% CI 1.30-1.83), typical angina (OR 1.96, 95% CI 1.69-2.27), hypertension (OR 1.29, 95% CI 1.11-1.49) and positivity of any non-invasive test.

Conclusions
In patients with CCS the diagnosis of non-obstructive CAD is associated with a suboptimal medical treatment. On the other hand, the diagnosis of anatomical obstructive CAD drives revascularization procedures, independently of documenting inducible ischemia. The intensity of treatment management depends on the overall estimation of patient risk based more on clinical variables and positivity of any diagnostic test than on specific disease phenotypes.Treatment according to CAD phenotypePredictors of revascularization or OMT