Original article
Prevalence and Prognosis of Nonobstructive Coronary Artery Disease in Patients Undergoing Coronary Angiography or Coronary Computed Tomography Angiography: A Meta-Analysis

https://doi.org/10.1016/j.mayocp.2016.11.016Get rights and content

Abstract

Objective

To evaluate the prevalence, clinical characteristics, and risk of cardiac events in patients with nonobstructive coronary artery disease (CAD).

Patients and Methods

We searched PubMed, EMBASE, and the Cochrane Library from January 1, 1990, to November 31, 2015. Studies were included if they reported prevalence or prognosis of patients with nonobstructive CAD (≤50% stenosis) among patients with known or suspected CAD. Patients with nonobstructive CAD were further grouped as those with no angiographic CAD (0% or ≤20%) and those with mild CAD (>0% or >20% to ≤50%). Data were pooled using random effects modeling, and annualized event rates were assessed.

Results

Fifty-four studies with 1,395,190 participants were included. The prevalence of patients with nonobstructive CAD was 67% (95% CI, 63%-71%) among patients with stable angina and 13% (95% CI, 11%-16%) among patients with non–ST-segment elevation acute coronary syndrome. The prevalence varied depending on sex, clinical setting, and risk profile of the population investigated. The risk of hard cardiac events (cardiac death or myocardial infarction) in patients with mild CAD was lower than that in patients with obstructive CAD (risk ratio, 0.28; 95% CI, 0.20-0.38) but higher than that in those with no angiographic CAD (risk ratio, 1.85; 95% CI, 1.52-2.26). The annualized event rates of hard cardiac events in patients with no angiographic CAD, mild CAD, and obstructive CAD were 0.3% (95% CI, 0.1%-0.4%), 0.7% (95% CI, 0.5%-1.0%), and 2.7% (95% CI, 1.7%-3.7%), respectively, among patients with stable angina and 1.2% (95% CI, 0.02%-2.3%), 4.1% (95% CI, 3.3%-4.9%), and 17.0% (95% CI, 8.4%-25.7%) among patients with non–ST-segment elevation acute coronary syndrome. The correlation between CAD severity and prognosis is consistent regardless of clinical presentation of all-cause death, myocardial infarction, total cardiovascular events, and revascularization.

Conclusion

Nonobstructive CAD is associated with a favorable prognosis compared with obstructive CAD, but it is not benign. The high prevalence and impaired prognosis of this population warrants further efforts to improve the risk stratification and management of patients with nonobstructive CAD.

Section snippets

Search Strategy

The guideline of the MOOSE (Meta-analysis of Observational Studies in Epidemiology)8 was followed for the conduct of the present systematic review and meta-analysis. We searched PubMed, EMBASE, and the Cochrane Library for the current literature. Detailed search strategies are given in Supplemental Methods (available online at http://www.mayoclinicproceedings.org). The last search was performed on November 1, 2015. Reference lists from these identified reports and reviews were manually screened

Results

Our literature search yielded 2682 relevant articles after duplication removal, of which 103 articles warranted full-text review for detail. After exclusion, we finally identified 54 studies that met the inclusion criteria and provided at least 1 end point of interest (Figure 1). Of these 54 studies, 44 studies with 1,394,057 patients reported prevalence of nonobstructive CAD and 41 studies with 309,311 patients reported at least 1 of the clinical outcomes of interest (median follow-up 27.6

Discussion

To our knowledge, this is the first comprehensive review of the current literature in a meta-analytic approach, assessing the prevalence, clinical characteristics, and prognostic value of nonobstructive CAD in patients referred for CA or CCTA. In this meta-analysis, we found that those with nonobstructive CAD accounts for 67% of patients with stable angina and 13% of patients with NSTE-ACS. Patients with nonobstructive CAD overall have a better prognosis than do those with obstructive CAD, but

Conclusion

In this meta-analysis, we found that nonobstructive CAD is common and that the prevalence varies depending on sex, clinical setting, and risk profile. Patients with mild CAD, identified by either CA or CCTA, have a lower risk of hard cardiac events than do those with obstructive CAD but a higher risk of events than do those with no angiographic CAD. Given the impaired prognosis and heterogeneity of mechanisms, more comprehensive evaluation is proposed. Further research is warranted to determine

Acknowledgments

We thank Fu Ying Tian, PhD, and Yi Zhou, MD, MPH, for their assistance with statistical analyses and Charles Resor, MD, MSc, for his assistance with editing and formatting the manuscript.

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    For editorial comment, see page 323

    Grant Support: This work was supported by the Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support (grant no. ZYLX201303), the National Key Clinical Specialty Construction Project (2013-2014), and the “Beijing Municipal Administration of Hospitals” Ascent Plan (code DFL20150601).

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