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Diagnosis of patients with angina and non-obstructive coronary disease in the catheter laboratory
  1. Haseeb Rahman1,
  2. David Corcoran2,
  3. Muhammad Aetesam-ur-Rahman3,
  4. Stephen P Hoole3,
  5. Colin Berry2,
  6. Divaka Perera1
  1. 1 The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
  2. 2 British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
  3. 3 Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
  1. Correspondence to Professor Divaka Perera, Department of Cardiology, St. Thomas Hospital, London SE1 7EH, UK ; divaka.perera{at}


Around 40% of all patients undergoing angiography are found to have normal coronary arteries or non-obstructive coronary artery disease (NOCAD). Despite the high prevalence, this is a group who rarely receive a definitive diagnosis, are frequently labelled and managed inappropriately and by and large, continue to remain symptomatic. Half of this group will have coronary microvascular dysfunction (CMD), associated with a higher rate of major adverse cardiovascular events; identifying CMD represents a therapeutic target of unmet need. As the pressure wire has revolutionised our ability to interrogate epicardial coronary disease during the time of angiography, measuring flow can similarly classify NOCAD during a single procedure. Assessment of flow is a function that is already integral to some pressure wires and furthermore, the familiarity and usage of the combined Doppler and pressure wire is rapidly increasing—these are techniques that readily lend themselves to the skillset of a practising interventional cardiologist. We present a structured algorithm designed for cardiologists who frequently encounter NOCAD in the catheter laboratory, identifying specific disease phenotypes within this heterogeneous population with linked therapy. This review paper clearly explains the rationale for this algorithm and outlines its applicability to routine clinical practice and also, the importance of phenotyping for future research. Ultimately, personalised therapy could improve outcomes for both patients and healthcare providers; while these approaches in turn will need robust evaluation to ensure that they improve both clinical outcomes and health economic benefits, this proposal will provide a framework for future trials and evaluations.

  • chronic coronary disease
  • cardiac catheterization and angiography
  • quality and outcomes of care

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  • Contributors All authors contributed to equally to the material within this manuscript.

  • Funding HR and DC were funded by British Heart Foundation Clinical Research Training Fellowships (FS/16/49/32320 and FS/14/15/30661, respectively).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

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