Long-term efficacy of endotype-based drug therapy on quality of life and symptom management in coronary vasomotion disorders

Abstract Background In patients with angina pectoris without obstructive coronary artery disease (ANOCA), coronary vasomotion disorders are a common cause for their symptoms. However, the heterogeneous clinical presentation resulting from a broad spectrum of subtypes (so-called endotypes) poses a major therapeutic challenge. Many patients suffer from long-term refractory symptoms and severely impaired quality of life. Purpose The purpose of this study was to evaluate the long-term benefits of an endotype-based drug therapy on quality of life and symptom management in ANOCA patients. Methods From the initial population of 50 patients (enrolled between 04/2021 and 02/2022) with a confirmed diagnosis of a coronary vasomotion disorder and subsequent targeted guideline-based endotype-adapted antianginal therapy, a total number of 38 patients (53% women, 65±15 years), were followed up over a period of 3 years (i.e. 76%). Initially, the efficacy and tolerability of the medications were closely monitored and adjusted over a period of 3 months. Thereafter, patients were offered outpatient visits if required. The quality of life was assessed quantitatively (score 0-100) using the Seattle Angina Questionnaire-7 (SAQ7) on a monthly basis during the 3-month therapy adjustment and at long-term follow-up after 3 years. Results The endotypes were classified according to the diagnostically distinguishable subtypes (coronary spasm: n=21; microvascular vasodilatation disorder: n=3; combined vasomotion disorder: n=14). The initial clinically relevant improvement in the SAQ7-Summary score by an average of 16 points after 3 months of endotype-based antianginal therapy (44±16 vs. 60±23; p0.001) even persisted after 3 years (44±16 vs. 63±23; p0.001). Of these patients, 63% experienced either further improvement in the clinically relevant range (5 points; n=19) or no change (5 points, n=5) after 3 years, while a clinically relevant aggravation (≥5 points) was recorded in 37% of the study population (n=14). Regarding the endotypes, 83% of the patients with isolated coronary spasm or vasodilation disorder benefited sustainably from targeted endotype-based therapy with an improved or unchanged SAQ7-Summary score. In patients with combined vasomotion disorders, long-term efficacy was only achieved in 29% of the patients. Comparing the medication after 3 years with the medication at 3-month follow-up under targeted therapy, patients reported a significant decrease in short-acting nitrate intake (p=0.021). For other antianginal drugs (calcium channel antagonists, long-acting nitrates, molsidomine, beta blockers, ranolazine) or basic treatment drugs (ACE inhibitors, statins) no significant changes were observed within the entire study population. Conclusion Targeted endotype-based drug therapy can contribute decisively to a long-term improvement of symptoms and quality of life, especially in ANOCA patients with isolated coronary spasm or microvascular vasodilation disorder.