What is the clinical evidence from this study?

Study design: Cohort. Population: Angina and nonobstructive coronary arteries (ANOCA) (n=381). Intervention: Hyperemic coronary flow velocity (hCFV) assessment vs. Higher hCFV (>0.44 m/s) or CFVR alone. Primary outcome: Major adverse cardiovascular events (MACE) (adjusted HR 6.6, p=0.001).

What question did this study set out to answer?

To evaluate whether hyperemic coronary flow velocity enhances risk prediction for major adverse cardiovascular events in patients with angina and nonobstructive coronary artery disease.

April 14, 2026Open Access

The Incremental Prognostic Value of Hyperemic Coronary Flow Velocity in Patients with Angina and Nonobstructive Coronary Artery Disease

Key Result

Reduced hyperemic coronary flow velocity (≤ 0.44 m/s) independently predicted major adverse cardiovascular events in ANOCA patients with CFVR < 2.5 (adjusted HR 6.6, p=0.001).

Key Points

To evaluate whether hyperemic coronary flow velocity enhances risk prediction for major adverse cardiovascular events in patients with angina and nonobstructive coronary artery disease.
Analyzed data from 246 consecutively enrolled ANOCA patients and a validation cohort of 135 patients.
Measured coronary flow velocity reserve and hyperemic coronary flow velocity using transthoracic Doppler.
Tracked major adverse cardiovascular events over a median follow-up of 28.8 months.
27 patients (10.9%) experienced major adverse cardiovascular events during the follow-up period.
Hyperemic coronary flow velocity independently predicted major adverse cardiovascular events among patients with CFVR < 2.5.
Combined CFVR and hyperemic coronary flow velocity improved stratification for risk of adverse events.

Study Design

Type

Cohort (n=381)

Structured PICO

Does hyperemic coronary flow velocity (hCFV) improve risk prediction for MACE in patients with angina and nonobstructive coronary artery disease?

Population

381 patients (246 derivation cohort, 135 validation cohort) with angina and nonobstructive coronary arteries (ANOCA)

Intervention

Hyperemic coronary flow velocity (hCFV) measurement via transthoracic Doppler of the mid-distal LAD

Comparator

Coronary flow velocity reserve (CFVR) and clinical risk factors alone

Outcome

Major adverse cardiovascular events (MACE) at median 28.8 months follow-upcomposite

Reduced hyperemic coronary flow velocity provides incremental prognostic value beyond coronary flow velocity reserve for identifying high-risk patients with angina and nonobstructive coronary arteries.

Main Result

Effect estimate: adjusted HR 6.6

Absolute Event Rate: 35.5% vs 10.5%

p-value: p=0.001

Abstract

ABSTRACT Risk stratification in patients with angina and nonobstructive coronary arteries (ANOCA) remains suboptimal. Coronary flow velocity reserve (CFVR) is prognostic but susceptible to hemodynamic variability; we evaluated whether hyperemic coronary flow velocity (hCFV) improves risk prediction. We analyzed 246 consecutively enrolled ANOCA patients and an independent validation cohort ( n = 135). Transthoracic Doppler of the mid‐distal LAD quantified CFVR and hCFV. The primary end point was major adverse cardiovascular events (MACE). During a median follow‐up of 28.8 months, 27 patients (10.9%) experienced MACE. Both CFVR and hCFV were significantly associated with MACE. Among patients with CFVR 0.44 m/s; Group C: CFVR < 2.5 with hCFV ≤ 0.44 m/s), with Group C exhibiting the highest risk of MACE (35.5% vs. 6.3%, 10.5%, p < 0.01). Adding reduced hCFV to a model including clinical risk factors and CFVR improved prediction (IDI 0.05, p = 0.011; NRI 0.23, p = 0.0023) and was confirmed in the validation cohort. Reduced hCFV provides incremental prognostic value beyond CFVR and offers a practical approach to identify high‐risk ANOCA patients.