International Journal of Research in Medical Sciences

Alftailah HAM et al. Int J Res Med Sci. 2024 Aug;12(8):2740-2746

www.msjonline.org pISSN 2320-6071 | eISSN 2320-6012

DOI: https://dx.doi.org/10.18203/2320-6012.ijrms20242203
Original Research Article

Non obstructive versus obstructive coronary artery disease documented

by coronary angiography: prevalence, diagnostic features in a single
center experience
Hasanain Ali Malallah Alftailah*, Ali K. N. Rufaish

Department of Internal Medicine, Al-Hussein Medical City, Kerbala Health Directorate, Kerbala, Iraq

Received: 06 June 2024

Accepted: 16 July 2024

*Correspondence:
Dr. Hasanain Ali Malallah Alftailah,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Coronary angiography often detects NOCAD. Stable angina or MI patients may have NOCAD, defined
as less than 50% luminal diameter decrease by visual assessment on coronary angiography. The study was to
determine the frequency of non-obstructive coronary artery disease in Al Hussain cardiac centre patients who
underwent CAG and the differences in clinical presentation and associated morbidity between the two groups.
Methods: Cross-sectional research was done at Karbala's al-Hussaini cardiac centre. CAG data from 167 IHD-like
patients between January and May 2021. NOCAD 42 individuals (stenosis <50%) were compared to 125 obstructive
CAD patients (≥50% stenosis).
Results: Between January and May 2021, 167 individuals received CAG for diagnostic, therapeutic, elective, or
emergency purposes. The study included 113 (67.7%) men and 54 (32.3%) women. Patients had an average age of
56.52±11.09 years, with a median of 58 years. Overall, 25.1% (n=42) of research participants had NOCAD. The
frequency of INOCA was 29.4% and MINOCA 19.1%. Patients with NOCAD were younger than those with
obstructive CAD (p<0.05). no significant gender, co morbidity, or clinical differences across groups.
Conclusions: We believe this is the first report of prevalence, risk factors, and clinical aspects in karbalai patients'
cardiac care centre in Iraq. NOCAD patients are younger and their medical history, clinical features, ECG, and serum
troponin are difficult to distinguish from OCAD.

Keywords: Coronary artery disease, Coronary angiography, Non-obstructive, Obstructive

INTRODUCTION epicardial arteries provide little resistance when there is

no significant stenosis. Pre-arterioles (100-500 μm)
Ischemic heart disease (IHD) is the leading cause of branch from these arteries and give rise to
death and morbidity worldwide in both men and women. intramyocardial arterioles (about 100 μm), which account
Identifying obstructive coronary artery disease (CAD) in for the majority of coronary vascular resistance.
symptomatic patients is the current diagnostic and Endothelial-dependent vasodilation regulates the
treatment paradigm for IHD. However, angiographic proximal and larger arterioles, while medium-sized
studies reveal that about two-thirds of women and one- arterioles respond to pressure changes, and distal
third of men with stable IHD do not have obstructive arterioles are influenced by metabolic activity.2
CAD.1 The coronary vasculature is composed of Atherosclerosis begins with fatty streaks in the intima,
epicardial arteries, pre-arterioles, and arterioles, with the characterized by lipid-laden macrophages (foam cells)
latter two forming the coronary microvasculature. The and extracellular matrix. These can evolve into fibrous

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 Alftailah HAM et al. Int J Res Med Sci. 2024 Aug;12(8):2740-2746

plaques with a lipid core covered by a fibrous cap. The patients with non-obstructive coronary artery disease
vasa vasorum, a network of micro vessels from the (<50% stenosis) and those with obstructive lesions
adventitial layer, supplies the outer arterial wall. As (>50% stenosis). Prior to data collection, the following
plaques grow, they develop their own microvascular approvals and permissions were secured: Authorization
network, which can hemorrhage and worsen the from the Arab board of medical specializations. Consent
condition. Advanced lesions may contain necrotic lipid- from the hospital where the data was collected. Informed
rich cores and calcified regions, leading to coronary consent from the patients participating in the study. The
artery remodeling.3 NOCAD is typically defined as study included 167 patients (113 males and 54 females)
stenosis of 50% or less in any major epicardial coronary who were clinically diagnosed with ischemic heart
artery. Despite the absence of significant stenosis, disease (IHD) through clinical features, ECG, and serum
ischemia with no obstructive coronary arteries (INOCA) troponin tests. These patients were admitted to the
is linked to poor cardiovascular outcomes. It is Karbala Cardiac Center and underwent coronary
increasingly recognized that many INOCA patients, angiography (CAG) between January 2021 and May
especially women, have coronary vasomotor 2021. Patients of both genders who presented with
abnormalities or coronary microvascular dysfunction clinical features and ECG findings indicative of IHD
(CMD). CMD involves increased microvascular were considered for the study.
resistance and reduced coronary blood flow due to
endothelial-dependent and independent processes, Inclusion criteria
affecting nearly half of INOCA patients and often
remaining undiagnosed and untreated.4 CMD Patients diagnosed with IHD, including myocardial
encompasses various abnormalities, including endothelial infarction (MI), unstable angina (UA), and chronic stable
dysfunction, microvascular and epicardial spasm, and angina. Patients undergoing elective CAG. Patients
vasomotor abnormalities. Previously referred to as undergoing emergency CAG transferred from the cardiac
cardiac syndrome X, current evidence suggests that CMD care unit.
patients have a significantly increased incidence of
adverse cardiac events, such as myocardial infarction, Exclusion criteria
heart failure, and sudden cardiac death.9,10 Studies
indicate that up to 49% of patients undergoing coronary Hemodynamically unstable patients whose data could not
angiography have no significant stenosis, and CMD may be collected. Uncooperative patients. Patients with
affect up to 60% of these patients. CMD often involves incomplete data.
endothelial dysfunction and autonomic dysregulation,
leading to vasospastic angina and myocardial ischemia. Data collection involved interviewing patients before
The autonomic nervous system, particularly adrenergic assessment to gather demographic information and
and muscarinic receptor pathways, plays a crucial role in medical history using a specially designed questionnaire.
coronary blood flow regulation, especially under stress. 5,6 Patients meeting the inclusion criteria were thoroughly
evaluated through history-taking, clinical examination,
CMD can be diagnosed using invasive and non-invasive and assessment of risk factors and comorbidities.
methods. Invasive methods include intracoronary Diagnostic tests included ECG, serum troponin tests, and
acetylcholine testing and coronary flow reserve (CFR) CAG performed using a Philips machine. The type of
measurement using Doppler or thermodilution chest pain or presentation regarding IHD was categorized
techniques. Non-invasive techniques like positron into typical (central, heavy chest pain with characteristic
emission tomography (PET) and cardiac magnetic radiations) and atypical presentations (left-sided chest
resonance imaging (CMR) are also used. Treatment often pain associated with shortness of breath and palpitations).
involves standard anti-angina medications like beta-
blockers and calcium antagonists. Novel treatments such Ethical considerations
as ivabradine and ranolazine show promise in improving
symptoms and coronary flow reserve in CMD patients. After explaining the study's objectives and the type of
Patients with MINOCA and INOCA syndromes are at information required during the interviews, all
increased risk for various cardiovascular diseases, participating patients provided verbal informed consent.
including cerebrovascular accidents and heart failure with Confidentiality was maintained throughout the data
preserved ejection fraction. CMD and CAD often coexist, collection, organization, analysis, and presentation
complicating the clinical management of IHD. 7,8 Aim of processes. Patients' identities were protected by replacing
study is to study the prevalence, risk factors and clinical their names with identifying numbers (file serial
presentations between patients with non-obstructive CAD numbers).
and obstructive CAD.
Statistical analysis
METHODS
It was conducted using SPSS® Software (version 26 for
This cross-sectional study was conducted at the Karbala Windows 10®). Qualitative data were presented as
Cardiac Center in Iraq, Kerbala, aiming to compare numbers and percentages, while continuous numerical

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 Alftailah HAM et al. Int J Res Med Sci. 2024 Aug;12(8):2740-2746

data were presented as mean±standard deviation. The chi- Table 1: Past medical history of study participants.
square test was used to assess relationships between
qualitative variables, and the student’s t-test was used to Medical history No. (%)
compare continuous numerical variables between two DM 84 50.3%
populations. A p value of <0.05 was considered History of DM
No DM 83 49.7%
statistically significant. HTN 96 57.5
Hypertension
No HTN 71 42.5
RESULTS History of HT and with 38 22.8
DM Without 129 72.2
A total of 167 patients with IHD underwent coronary
COPD 11 6.6
angiography were included in the study. 113 (67.7%) History of COPD
were males and 54 (32.3%) were females. As illustrate in No COPD 156 93.4
figure (1A). 7 cases were excluded because of incomplete History of smoking Smoker 57 43.1
data. Age of participants ranged from (20-82) years, the within 5 years Not Smoker 110 65.9
mean age of patients (56.52±11.09) with median (58) H. F. 27 16.2
years. The Age group of participants was presented in History of H.F No history of
140 83.8
figure (1B). H. F.
dyslipidemia 42 25.1
History of
No
dyslipidemia 125 74.9
Dyslipidemia
Yes 10 6
No co morbidity
and non-smoker
No 157 94

Participants of Chronic stable angina were found to be

102 (61.7%) of total cases, among them, obstructive
CAD observed in 70.6% and non-obstructive were
29.4%, as presented in figure 3

A B

Figure 1: (A) Gender distribution of study

participants, (B) age groups of participants.
According to WHO classifications: young 25-44,
middle 45-59, elderly >60 years.

The coronary angiography results were demonstrated that

about 125 cases were with obstructive lesions (74.9%)
while non-obstructive coronary arteries were 42 cases
(25.1%), as shown in table 3 and figure 2.
Figure 3: Angiographic results of stable
angina participants.
25.1%

Non obstructive 19.1%

Obstructive non obstructives
74.9% obstructive CAD
80.9%

Figure 2: Angiographic results of participants.

Figure 4: CAG results of MI participants.
Regarding the past medical history of study participants;
results were shown that the commonest disorder was By using the independent samples t-test there is
hypertension in (57.5%) of patients, followed by DM in significant difference between OCAD (median =60) and
(50.3%) of them, while smokers and negative past NOCAD (median =55), p value was 0.007. which means
medical history was found in (43.1%) and (6%) NOCAD patients were younger. As in table 2.
respectively as presented in table 1.

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Table 2: age per years in association between conditions like hypertension and diabetes are common
obstructive CAD and NOCA. among both OCAD and NOCAD groups.

Variables Mean S. D P value Table 4: frequency of comorbidities and risk factors

Obstructive in Obstructive CAD and in NOCAD groups.
57.85 10.199 0.002
CAD
NOCAD 52.57 12.747 Obstructive NOCAD
CAD (n=125) (n=42) P
Variables
The results in Table 3 describe the characteristics of the (74.9%) (25.1%) value
study participants divided into two groups: those with N (%) N (%)
obstructive coronary artery disease (CAD) based on Gender, female 36 (66.7) 18 (33.3) 0.092
angiography (CAG) and those without (NOCAD). In this Age (in years),
60 55 0.007
study, results were shown that the majority of participants median (IQR)
had obstructive CAD (74.9%) and males were more Smoker 38 (30.4) 19 (45.2) 0.079
common in the study (67.7%). The table shown an even Hypertension 74 (59.2) 22 (52.4) 0.474
spread across three age groups: young (14.4%), middle- Diabetes
aged (38.3%), and older adults (47.3%). Typical chest 64 (51.2) 20 (47.6) 0.688
mellitus
pain was the predominant symptom (78.4%), regardless Diabetes
of the CAD status. mellitus with 31 (24.8) 7 (16.7) 0.277
hypertension
Table 3: The demographic and clinical characteristics Dyslipidaemia 34 (27.2) 8 (19.0) 0.292
of the study groups. Heart failure 18 (14.4) 9 (21.4) 0.296
COPD 10 (8.0) 1 (2.4) 0.204
Variable Category No. %
No co morbidity
Obstructive 125 74.9 8 (6.4) 2 (4.8) 0.699
CAG results and no smoking
Non obstructive 42 25.1
Male 113 67.7
Gender Table 5: Assessment on admission among Obstructive
Female 54 32.3 CAD and in NOCAD groups.
Young 24 14.4
Age group
Middle 64 38.3 Obstructive NOCAD
Old 79 47.3 P
CAD (n=125) (n=42)
Variables value
Symptoms at Typical chest pain 131 78.4 N (%) N (%)
presentation Atypical chest pain 36 21.6 Typical chest
95 (76.8) 35 (83.3) 0.373
Chronic stable angina 102 61.1 pain
Acute coronary Atypical chest
65 38.9 30 (23.2) 7 (16.7) 0.322
syndrome pain
Type of IHD Serum
Unstable angina 18 10.8
NSTEMI 26 15.6 troponin 38 (30.4) 9 (21.4) 0.263
STEMI 21 12.5 positive
Negative S. troponin 120 71.9 Chronic
S. Troponin 72 (57.6) 30 (71.4) 0.112
Positive troponin 47 28.1 stable angina
Acute
In Table 4, independent samples t-test was used to coronary 53 (42.4) 12 (28.6) 0.112
examine the mean differences in the frequency of syndrome
comorbidities and risk factors in patients with obstructive MI 38 (30.4) 9 (22.8) 0.263
CAD (OCAD) compared to those with non-obstructive UA 15 (12.0) 3 (5.8) 0.192
CAD (NOCAD). Results were indicated that age was the STEMI 18 (14.4) 3 (8.1) 0.220
only statistically significant variable (p value<0.05) NSTEMI 20 (16.0) 6 (14.7) 0.791
between the two groups. The median age for patients with ECG at
OCAD was 60 years old, while the median age for those admission
with NOCAD was 55 years old. Results were shown an anterior wall 60 (48.0) 19 (45.2) 0.756
interesting finding included a trend towards large number ischemia
of females in NOCAD group (33.3% vs. 66.7% in Lateral wall
OCAD). While Smoking rates were higher in the 45 (36.0) 19 (45.2) 0.287
ischemia
NOCAD group (45.2% vs 30.4% in OCAD). Nferior wall
Hypertension and Diabetes Mellitus were common in 36 (28.8) 12 (28.6) 0.977
ischemia
both groups. Overall, the table suggests that middle age is Anterolaiteral
a key risk factor for NOCAD. While some other 10 (8.0) 6 (14.3) 0.231
wall ischemia

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Table 5 shows findings on admission assessment among significantly younger (mean age 52.57 years) compared
patients with obstructive coronary artery disease (OCAD) to those with obstructive CAD (OCAD) (mean age 57.85
compared to those without obstructive CAD (NOCAD). years). This age difference is consistent with Kissel et al
There were no statistically significant differences cohort study in Canada and Pizzi et al meta-analysis
between the two groups in most of the assessed variables. published in AHA 2016, which used a larger sample size
Patients have been categorized before undergoing (15,16). Gender: The study found no significant sex
coronary angiography into typical and atypical differences between the NOCAD and OCAD groups
presentation. typical chest pain in OCAD group was 95 (Table 3). This contrasts with the Women Ischemia
(76.8%) and in NOCAD group was 35 (83.3%). Chronic Syndrome Evaluation (WISE) cohort study, which
stable angina was a slightly higher rate in the NOCAD reported a higher prevalence of NOCAD in females,
group. while Rates of MI were around 30.4% in OCAD likely due to the higher proportion of women in WISE,
and 22.8% NOCAD groups. increasing the women-to-men ratio.17 Our study enrolled
54 females, which may appear small compared to the
Unstable angina (UA) and ST-segment elevation number of males but reflects efforts to avoid bias in sex-
myocardial infarction (STEMI) were less common than related NOCAD, given that most patients undergoing
other presentations, also non-ST segment elevation MI CAG at the Karbala Center for Cardiology were male. 18
(NSTEMI) rates were nearly similar between the two The study observed no significant differences in
groups. Results were also shown that the presence of symptoms between NOCAD and OCAD groups
various ECG wall ischemia patterns (anterior, inferior, regarding typical or atypical chest pain, dyspnea,
anterolateral) during admission assessment was similar palpitations, and fatigability. This finding aligns with
between OCAD and NOCAD groups. these findings Mayala et al observational study in Wuhan, China, and
suggested that assessment on admission may not always Lanza et al literature review from the Cardiology
be sufficient to differentiate between obstructive CAD Institute, Rome, Italy.19,20 ECG changes: Anterior and
and non-obstructive CAD. While some clinical suspicion inferior lead changes were more common in NOCAD,
might be raised by certain findings. but there were no significant differences compared to
OCAD patients (Table 4). This observation contrasts with
DISCUSSION only one study, which found more inferior lead changes
in NOCAD, likely due to its smaller sample size.21 The
This study's sample size of 167 IHD patients is study found no significant differences in the prevalence
comparable to other studies. For instance, Lanza et al.'s of diabetes mellitus between the obstructive CAD and
study at the Institute of Cardiology, Università Cattolica INOCA groups, consistent with Aribas et al systematic
del Sacro Cuore, Rome, Italy, involved 178 patients (9). review.22 However, Najib et al.'s retrospective study
Similarly, Bairey Merz et al. conducted a study with 185 reported higher diabetes prevalence in obstructive CAD
patients at the Department of Cardiology, Gosford patients.23 No differences were observed in the
Hospital, Northern Sydney Central Coast Gosford, prevalence of hypertension between the NOCAD and
Australia (10). NOCAD: The prevalence of non- OCAD groups, consistent with Pasupathy et al findings in
obstructive coronary artery disease (NOCAD) among Adelaide, Australia.25 The same pattern was observed for
patients who underwent coronary angiography (CAG) dyslipidemia and heart failure, with no significant
was 25.1% (Figure 2, Table 1). This finding aligns differences affecting the identification of NOCAD
closely with Farrehi et al.'s study, which reported a patients.26 Traditional atherosclerosis risk factors such as
NOCAD prevalence of 14.7%-22.0% across three hypertension, diabetes mellitus, and dyslipidemia were
southeastern Michigan hospitals and a composite sample found to be associated with an increased risk of CMD.
from New York State.11 INOCA: Among patients
classified with ischemia with no obstructive coronary CONCLUSION
arteries (INOCA), the prevalence of stable angina
pectoris without coronary artery obstruction was 29.4% The prevalence of NOCAD was 25.1%, with chronic
(Figure 3). This is consistent with Ford et al report that at stable angina and MI accounting for 29.4% and 19.1%,
least one-third of angina patients undergoing invasive respectively, of their patient groups. NOCAD patients
coronary angiography in some UK centers had no were generally younger. Clinical presentation and
obstructive CAD.12 It also aligns with Sucato et al traditional risk factors were similar between NOCAD and
literature review, which found that 20-30% of patients obstructive CAD patients, making differentiation based
undergoing coronary angiography for chest pain on clinical features alone difficult. Non-traditional risk
suggestive of CAD had normal coronary angiograms. 13 factors may also play a significant role.
MINOCA: The prevalence of myocardial infarction with
non-obstructive coronary arteries (MINOCA) was 19.1% Funding: No funding sources
among all acute myocardial infarction (AMI) cases Conflict of interest: None declared
(Figure 4). This finding is consistent with Chow et al Ethical approval: The study was approved by the
literature review, which confirmed that the prevalence of Institutional Ethics Committee
MINOCA in various studies ranged from 5%-25% of all
MI events.14 Age: Patients with NOCAD were

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