CASE & Plan:
64-year-old male presented with CCS Class III angina and a positive stress MPI for multivessel ischemia done as pre-op risk stratification for laminectomy. A Cardiac Cath on August 1, 2023 revealed 2 V CAD: 70% proximal/mid LAD underexpanded calcified multi-stent ISR with neoatherosclerosis, 70% stent jailed D2 (1,1,1), 90% LCx-LPL1 ISR, LCx-OM2 total occlusion ISR with SYNTAX Score of 28 and LVEF 48%. Patient underwent successful intervention of LCx-LPL1. Patient is now planned for stage PCI of calcified underexpanded LAD/D2 ISR using RotaTripsy and Mini-Crush stenting with OCT guidance.
Q&A
Q
Is the movement to standardize ANOCA management one of the most important developments of this decade?
A.
Yes development of the Microvascular disease (MVD) network is a very important development in recognizing ANOCA as an important disease entity and subsequently outlining the system process for identifying, diagnosing and then treating the individual ANOCA phenotype.
Q
How many patients are afflicted by ANOCA? Millions?
A.
Approximately 20-25% of pts with CCD (10 million) are suffering from ANOCA; hence around 2-2.5 million pts are suffering from ANOCA.
Q
It seems ANOCA is one of the most crippling conditions in CAD that is simply ignored after a negative cath?
A.
That is absolutely correct that ANOCA pts are frustrated with symptoms and we did not have any appropriate diagnosis for them except saying that they have normal/nonobstructive coronaries. We have been reassuring them that all will be ok soon; but pt continues to have frustrating disabling symptoms.
Q
Are you using the protocol Dr. Sweeney described?
A.
Yes we now do MVD testing in majority of these pts after suspecting ANOCA in these prospective pts.
Q
It appears the protocol is too academic and certain pragmatic changes will help its rational delivery and help with reimbursement?
A.
That is correct that MVD testing protocol is cumbersome and takes total 1-2 hrs and needs to be planned because Acetylene Choline needs to be prepared by Pharmacy and solution is good only for 4 hrs.
Q
How would reimbursement work?
A.
Reimbursement is a major issue in MVD assessment and does not justify the time consumes in doing the MVD testing, drugs required as well as various catheters used for the assessment. Hope in future, reimbursement will catch up for MVD testing just like it happens for other devices in early stages.
Q
Will cath labs now have separate Coronary Function Testing protocols, designated areas, scheduling, and teams?
A.
Clearly there are set defined protocols for testing of various aspects of ANOCA and MVD testing. We can make a significant impact only by standardizing the protocols and making them simpler.
Q
It seems Acetyl Choline that we had forgotten will become a mainstay again?
A.
Actually Acetyl Choline (AcH) to evaluate Vasospatic angina, is an ophthalmic solution and converted in various dilution to be used intravenously with increasing doses gradually. AcH availability is currently a major factor in performing the MVD testing.
Q
Regarding OCTIVUS, a landmark trial, what is your practical take-home message?
A.
Overall message of OCTIVUS trial is that both devices are safe and gives good results but IVUS has an edge over OCT in complex lesions and gets better final MSA but no effect on followup MACE.
Q
Looking at the future, OCT or IVUS?
A.
OCT with its various AI incorporated algorithms, has a better future then IVUS along with data suggesting its use without contrast dye, just saline and other noniodinated compounds/solution.
