Improvement of symptoms and quality of life in patients with coronary vasomotion disorders by endotype-based drug therapy

Abstract Introduction In patients with angina pectoris and/or signs of ischemia but no obstructive coronary artery disease (ANOCA) coronary vasomotion disorders are a frequent cause for their symptoms. However, the heterogeneous clinical presentation resulting from a wide spectrum of subtypes (so-called endotypes) poses a major therapeutic challenge. Many patients suffer from long-term refractory symptoms and severely reduced quality of life. Purpose The purpose of this study was to demonstrate that the quality of life of these patients can be improved by an endotype-based drug therapy. Methods A total of 50 patients (56% women, mean age 63±14 years) with a confirmed diagnosis of coronary vasomotion disorder were enrolled between April 2021 and February 2022. The endotypes were classified according to the diagnostically distinguishable subtypes (coronary spasm: n=30; vasodilatation disorder: n=3; combined vasomotion disorder: n=17). Based on the guideline recommendations of the European Society of Cardiology, an individual endotype-adapted medication was prescribed. The efficacy and tolerability of the medications were monitored over a period of 3 months. In addition, the quality of life was assessed quantitatively (score 0-100) using the Seattle Angina Questionnaire-7 (SAQ-7) at baseline and after 1, 2 and 3 months. The symptoms at home were documented weekly using a patient diary (PROM). Results Within the study population, arterial hypertension (74%) and dyslipidemia (80%) were among the most frequent concomitant cardiovascular risk factors. After 3 months of endotype-based antianginal therapy, a clinically relevant and significant improvement of 15 points on average in the SAQ7-score was achieved in 70% of the patients within the entire cohort (p<0.001), while no change (<5 points) was recorded in 14% of the study participants and 16% experienced an aggravation in the clinically relevant range (≥5 points). Accordingly, the PROM mood score (scale 1-5) also showed a significant improvement of 0.5 points (2.7±0.8 vs. 3.2±0.8; p<0.001) as well as a significant decrease in monthly number of chest pain attacks by 38% (11.7±13.6 vs. 7.3±15.4; p=0.041) and nitroglycerin intake by 67% (2.7±5.9 vs. 0.9±2.6; p=0.004). When comparing the initial and final medication, a significant increase (33%) in the intake of calcium channel antagonists (non-DHP) was recorded in patients with coronary spasm (p=0.004). Within the patient group with combined vasomotion disorders, statins, ezetimibe and ranolazine were taken significantly more often by 35% respectively at the end of the observation period (p=0.031). Conclusion Targeted endotype-based drug therapy can contribute decisively to a clinically relevant improvement of symptoms and quality of life in ANOCA patients.Outcome of the whole patient cohortSAQ improvement during follow-up