Persisting chest pain in nonobstructive coronary artery disease

Extract

This editorial refers to ‘Natural history of patients with insignificant coronary artery disease’, by R. Tavella et al., on page 117.

Chest pain is the most common symptom of coronary artery disease (CAD) prompting subjects to seek attention from physicians. Angina is an important predictor of outcomes and to a large extent determines health-related quality of life (HRQoL) even in the overall apparently health population.¹ Furthermore, physical disability caused by angina has an impact on prognosis as well as on HRQoL.² Early reports have demonstrated the value of supplementing the clinical presentation of angina with angiographic information.³ Angiography does not miss significant life-threatening disease. The severity and the extent of obstructive coronary lesions demonstrated by angiography are powerful predictors of death. Clinical presentation is also a strong predictor of mortality, as type and severity of chest pain act indirectly as predictors because of their association with the severity of the coronary stenosis. For this reason, studies designed to evaluate the influence of medical or interventional therapy on survival and/or HRQoL should utilize angiographic findings in the selection of groups of patients. The results of the study by Tavella et al.⁴ are at variance with these ‘rules of thumb’. These authors looked at patients with stable CAD and reported 1% of recurrence of myocardial infarction in a group of 253 patients with chest pain and non-obstructive CAD who were followed for 12 months. Similar outcomes were found in those patients labelled as obstructive CAD who, indeed, had clinically negligible differences in prognosis: 1% death and 1% myocardial infarction during the same time span. Similarity was even more when evaluating HRQoL status in the two groups of patients. These findings raise several important issues.