Coronary Microvascular Angina - CorMicA

Sep 25, 2018
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Author/Summarized by Author:
Dharam J. Kumbhani, MD, SM, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
British Heart Foundation
Date Presented:
09/25/2018
Date Published:
09/25/2018
Date Updated:
09/25/2018
Original Posted Date:
09/25/2018
References

Contribution To Literature:

The CorMicA trial showed that a tiered approach for assessment for microvascular and/or vasospastic angina among patients with stable angina and no evidence of significant epicardial disease is superior to usual care.

Description:

The goal of the trial was to evaluate the efficacy of a tiered assessment among patients with angina without evidence of obstructive coronary artery disease (CAD).

Study Design

Patients with no evidence of anatomical or functional epicardial disease were randomized in a 1:1 fashion to either a diagnostic procedure to assess for microvascular/vasospastic angina (n = 75) or standard care after the initial angiogram (n = 76). In the active assessment arm, patients were treated with beta-blockers and lifestyle modification if they had evidence of microvascular angina, calcium channel blockers and lifestyle modification if they had evidence of vasospastic angina, and if neither was present, then antianginal therapies were stopped.  

  • Total screened: 391
  • Total number of enrollees: 151
  • Duration of follow-up: 6 months
  • Mean patient age: 61 years
  • Percentage female: 55%
  • Percentage with diabetes: 20%

Inclusion criteria:

  • Age ≥18 years – Angina (Rose questionnaire) Definite or Probable
  • Clinically indicated invasive coronary angiography

Exclusion criteria:

  • Noncoronary indication for invasive angiography (e.g., valve disease)
  • Inability to give informed consent
  • Demonstration of obstructive CAD (≥50% diameter stenosis and/or fractional flow reserve ≤0.80) during coronary angiography

Other salient features/characteristics:

  • Current smoker: 18%
  • Predicted 10-year coronary heart disease risk: 19%

Principal Findings:

The primary endpoint, change in Seattle Angina Questionnaire (summary score at 6 months was 11.7 units higher in the arm that underwent active assessment compared with control; 95% confidence interval 5.0-18.4, p = 0.001).

  • Improvement in physical limitation: 14.5 U, p < 0.001
  • Improvement in angina frequency: 9.3 U, p < 0.001

Secondary outcomes for active assessment vs. control:

  • Change in diagnosis: 52% vs. 0%, p < 0.001
  • Diagnostic certainty re: microvascular/vasospastic angina: 83% vs. 18%, p < 0.001
  • Major adverse cardiac events at 6 months: 2.6% vs. 2.6%

Interpretation:

The results of this trial indicate that a tiered approach for assessment for microvascular and/or vasospastic angina among patients with stable angina and no evidence of significant epicardial disease is superior to usual care. This approach allowed for a change in diagnosis in more than half of the patients, and there was diagnostic certainty regarding microvascular/vasospastic angina in >80% of patients. By tailoring therapy accordingly, there were commensurate improvements in angina from the patients’ perspective. These are very interesting findings and suggest a greater role for these measures in routine practice, although provocative testing for vasospastic angina currently has a Class IIb indication in the US guidelines (recommended only if empiric treatment trial is ineffective).

References:

Ford TJ, Stanley B, Good R, et al. Stratified Medical Therapy Using Invasive Coronary Function Testing in Angina: CorMicA Trial. J Am Coll Cardiol 2018;Sep 25:[Epub ahead of print].

Presented by Dr. Thomas J. Ford at the Transcatheter Cardiovascular Therapeutics meeting (TCT 2018), San Diego, CA, September 25, 2018.

Keywords: TCT18, Transcatheter Cardiovascular Therapeutics, Adrenergic beta-Antagonists, Angina Pectoris, Variant, Angina, Stable, Angiography, Calcium Channel Blockers, Coronary Angiography, Coronary Artery Disease, Life Style, Microvascular Angina, Treatment Outcome


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