Tıkayıcı Koroner Arter Hastalığı Olmayan İskemi (INOCA) Hastalarında Karotis İntima-Media Kalınlığı: Erken Aterosklerozun Bir Göstergesi

Öz

Amaç: Tıkayıcı koroner arter hastalığı olmayan iskemi (INOCA), olumsuz kardiyovasküler sonuçlarla ilişkili, klinik açıdan önemli bir durum olarak giderek daha fazla kabul görmektedir. Karotis intima-media kalınlığı (KİMK), erken aterosklerozun dolaylı bir belirteci olup INOCA’daki sistemik vasküler tutulum hakkında fikir verebilir. Bu çalışmada, INOCA hastaları ile sağlıklı kontroller arasında KİMK değerlerinin karşılaştırılması amaçlanmıştır. Gereç ve Yöntem: Bu tek merkezli olgu-kontrol çalışmasına, Mayıs 2018 ile Ocak 2024 tarihleri arasında INOCA tanısı alan 145 hasta (ortalama yaş: 53,2 ± 9,1 yıl; %40 erkek) ve 150 sağlıklı kontrol (ortalama yaş: 56,7 ± 7,4 yıl; %44 erkek) dahil edildi. INOCA tanısı; tipik anjina varlığı, treadmill egzersiz testi veya miyokard perfüzyon sintigrafisinde objektif iskemi kanıtı bulunması ve invaziv koroner anjiyografide tıkayıcı epikardiyal koroner arter darlığı (>%50) veya vazospazm saptanmaması esas alınarak konuldu. Karotis intima-media kalınlığı (KİMK), yüksek çözünürlüklü B-mod ultrasonografi kullanılarak sol ana karotis arterden ölçüldü. Gruplar arasında karşılaştırmalar yapıldı ve KİMK’nin tanısal performansını değerlendirmek için ROC eğrisi analizi uygulandı. Bulgular: INOCA ve kontrol grupları arasında temel demografik, ekokardiyografik ve laboratuvar parametreleri açısından anlamlı fark saptanmadı (tüm p > 0,05). Ortalama KİMK, INOCA grubunda kontrollerden anlamlı olarak daha yüksekti (0,58 ± 0,13 mm’ye karşı 0,52 ± 0,11 mm; p < 0,001). ROC analizi, KİMK >0,54 mm değerinin INOCA’yı %59 duyarlılık ve %52 özgüllükle öngördüğünü gösterdi (AUC: 0,605; %95 GA: 0,540–0,669; p = 0,002). Sonuç: INOCA hastalarında, sağlıklı kontrollere kıyasla anlamlı derecede artmış karotis intima-media kalınlığı saptandı. Bu bulgu, INOCA’nın erken sistemik ateroskleroz ile ilişkili olabileceğini düşündürmektedir. KİMK ölçümü, bu hasta grubunda yüksek riskli bireyleri belirlemek için basit ve noninvaziv bir yöntem olabilir.

Anahtar Kelimeler

• Mikrovasküler anjina
• Karotis intima-media kalınlığı
• Subklinik ateroskleroz
• Ekokardiyografi
• Tıkayıcı koroner arter hastalığı olmayan iskemi

Destekleyen Kurum

None

Etik Beyan

T.C Kafkas Üniversitesi Tıp Fakultesi Dekanlığı Etik Kurul Başkanlığınca 26/06/2018 tarih ve 80576354-050-99/132 karar no ile onay almıştır

Teşekkür

None

Carotid Intima-Media Thickness in Patients with Ischemia and No Obstructive Coronary Arteries (INOCA): A Marker of Early Atherosclerosis

Öz

Objective: Ischemia with no obstructive coronary arteries (INOCA) is increasingly recognized as a clinically relevant entity associated with adverse cardiovascular outcomes. Carotid intima-media thickness (CIMT) is a surrogate marker of early atherosclerosis and may provide insight into the systemic vascular involvement in INOCA. This study aimed to compare CIMT between patients with INOCA and healthy controls. Material and Method: A total of 145 patients with INOCA (mean age: 53.2 ± 9.1 years, 40% male) and 150 healthy controls (mean age: 56.7 ± 7.4 years, 44% male) were enrolled in this single-center case-control study between May 2018 and January 2024. The diagnosis of INOCA was based on the presence of typical angina, objective evidence of ischemia on treadmill exercise testing or myocardial perfusion scintigraphy, and without angiographic evidence of obstructive epicardial coronary artery stenosis (>50%) or vasospasm during invasive coronary angiography. CIMT was measured from the left common carotid artery using high-resolution B-mode ultrasonography. Comparisons between groups were performed, and receiver operating characteristic (ROC) curve analysis was conducted to assess the diagnostic performance of CIMT. Results: Baseline demographic, echocardiographic, and laboratory parameters were similar between INOCA patients and controls (all p > 0.05). Mean CIMT was significantly higher in the INOCA group compared with controls (0.58 ± 0.13 mm vs. 0.52 ± 0.11 mm, p < 0.001). ROC analysis demonstrated that CIMT >0.54 mm predicted the presence of INOCA with a sensitivity of 59% and a specificity of 52% (AUC: 0.605, 95% CI: 0.540–0.669, p = 0.002). Conclusion: Patients with INOCA exhibited significantly increased carotid intima-media thickness compared with healthy controls, suggesting that INOCA is associated with early systemic atherosclerosis. CIMT measurement may represent a simple and noninvasive method for identifying high-risk patients in this population.

Anahtar Kelimeler

• Microvascular angina
• Carotid intima-media thickness (CIMT)
• Subclinical atherosclerosis
• Echocardiography
• Ischemia with no obstructive coronary arteries (INOCA)

Destekleyen Kurum

None

Etik Beyan

It has been approved by the Ethics Committee of the Dean’s Office of the Faculty of Medicine, Kafkas University, Republic of Turkey, with the decision dated 26/06/2018 and numbered 80576354-050-99/132.

Teşekkür

None

Kaynakça

1. Bairey Merz CN, Pepine CJ, Walsh MN, Fleg JL. Ischemia and No Obstructive Coronary Artery Disease (INOCA): Developing Evidence-Based Therapies and Research Agenda for the Next Decade. Circulation 2017;135(11):1075-1092.
2. Ong P, Camici PG, Beltrame JF, et al. International standardization of diagnostic criteria for microvascular angina. Int J Cardiol 2018;250:16-20.
3. Jespersen L, Hvelplund A, Abildstrøm SZ, et al. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J 2012;33(6):734-744.
4. Taqueti VR, Di Carli MF. Coronary Microvascular Disease Pathogenic Mechanisms and Therapeutic Options: JACC State-of-the-Art Review. J Am Coll Cardiol 2018;72(21):2625-2641.
5. Lorenz MW, Markus HS, Bots ML, Rosvall M, Sitzer M. Prediction of clinical cardiovascular events with carotid intima-media thickness: a systematic review and meta-analysis. Circulation 2007;115(4):459-467.
6. Bugiardini R, Manfrini O, De Ferrari GM. Unanswered questions for management of acute coronary syndrome: risk stratification of patients with minimal disease or normal findings on coronary angiography. Arch Intern Med 2006;166(13):1391-1395.
7. Camici PG, Crea F. Coronary microvascular dysfunction. N Engl J Med 2007;356(8):830-840.
8. Crea F, Lanza GA. Angina pectoris and normal coronary arteries: cardiac syndrome X. Heart 2004;90(4):457-463.

9. Ong P, Safdar B, Seitz A, Hubert A, Beltrame JF, Prescott E. Diagnosis of coronary microvascular dysfunction in the clinic. Cardiovasc Res 2020;116(4):841-855.
10. Touboul PJ, Hennerici MG, Meairs S, et al. Mannheim carotid intima-media thickness and plaque consensus (2004-2006-2011). An update on behalf of the advisory board of the 3rd, 4th and 5th watching the risk symposia, at the 13th, 15th and 20th European Stroke Conferences, Mannheim, Germany, 2004, Brussels, Belgium, 2006, and Hamburg, Germany, 2011. Cerebrovasc Dis 2012;34(4):290-296.
11. Willeit P, Tschiderer L, Allara E, et al. Carotid Intima-Media Thickness Progression as Surrogate Marker for Cardiovascular Risk: Meta-Analysis of 119 Clinical Trials Involving 100 667 Patients. Circulation 2020;142(7):621-642.
12. Lorenz MW, Polak JF, Kavousi M, et al. Carotid intima-media thickness progression to predict cardiovascular events in the general population (the PROG-IMT collaborative project): a meta-analysis of individual participant data. Lancet 2012;379(9831):2053-2062.
13. Taqueti VR, Shaw LJ, Cook NR, et al. Excess Cardiovascular Risk in Women Relative to Men Referred for Coronary Angiography Is Associated with Severely Impaired Coronary Flow Reserve, Not Obstructive Disease. Circulation 2017;135(6):566-577.
14. Nambi V, Chambless L, Folsom AR, et al. Carotid intima-media thickness and presence or absence of plaque improves prediction of coronary heart disease risk: the ARIC (Atherosclerosis Risk in Communities) study. J Am Coll Cardiol 2010;55(15):1600-1607.
15. Pepine CJ, Anderson RD, Sharaf BL, et al. Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE (Women's Ischemia Syndrome Evaluation) study. J Am Coll Cardiol 2010;55(25):2825-2832.
16. Murthy VL, Naya M, Taqueti VR, et al. Effects of sex on coronary microvascular dysfunction and cardiac outcomes. Circulation 2014;129(24):2518-2527.
17. Kunadian V, Chieffo A, Camici PG, et al. An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. EuroIntervention 2021;16(13):1049-1069.