Review
Patients With Coronary Artery Disease Unsuitable for Revascularization: Definition, General Principles, and a Classification

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Abstract

In the present report, we review the phenotypes of coronary artery disease (CAD) patients unsuitable for revascularization procedures. We then analyze these phenotypes and propose a simple angiographic-based classification for patients with CAD unsuitable for revascularization. Under this classification, the following four distinct angiographic phenotypes are proposed: (1) suspected cardiac syndrome X; (2) limited territory at risk; (3) diffuse thread-like coronary atherosclerosis; and (4) end-stage CAD. It is hoped that such a classification system, as well as the general principles described in this report, will help to standardize the collection of epidemiological data on patients with refractory angina (RFA) and advanced CAD. It is also hoped that this system will be useful to extend the principles of clinical equipoise to the development of clinical trials of innovative therapies or devices for the treatment of RFA. Finally, we anticipate that the elaboration of this system, the first of its type in the literature, will stimulate discussion of what we feel to be a subject that has received insufficient attention in the literature, and ultimately to improved management of a challenging patient population.

Résumé

Dans ce rapport, nous revoyons les phénotypes des patients ayant une maladie coronarienne (MC) pour laquelle les procédures de revascularisation sont inappropriées. Nous analysons ensuite ces phénotypes et proposons une classification simple fondée sur l'angiographie pour les patients ayant une MC dont la revascularisation est inappropriée. Selon cette classification, les quatre phénotypes angiographiques distincts suivants sont proposés : (1) le syndrome X cardiaque suspecté; (2) le territoire limité à risque; (3) l'athérosclérose coronarienne filiforme diffuse; (4) la MC terminale. Il faut espérer qu'un tel système de classification, aussi bien que les principes généraux décrits dans ce rapport, contribueront à uniformiser la cueillette de données épidémiologiques des patients ayant une angine réfractaire (AR) et une MC avancée. Il faut aussi espérer que ce système sera utile pour étendre les principes de l'équilibre clinique au développement d'essais cliniques sur des traitements innovateurs ou des dispositifs pour le traitement de l'AR. Finalement, nous anticipons que l'élaboration de ce système, le premier de ce type dans la littérature, stimulera la discussion sur ce que nous croyons être un sujet ayant reçu peu d'attention dans la littérature, et en fin de compte qu'il améliorera la prise en charge thérapeutique de cette population difficile.

Section snippets

Rationale for a Classification System

The need for a classification system is supported by several reasons. Epidemiologically, more restrictive phenotypes will allow for refinement of the data available for each patient subset and help to actually constitute an identifiable population of people who are unsuitable for revascularization and living with RFA. Precise estimates of the prevalence of RFA are not available,3 leading to the potential for gross over- or underestimation of an affected population.4, 5 Likewise, there is

Definition of CAD unsuitable for revascularization

In order to propose specific phenotypes, we first offer the following operational definition of CAD unsuitable for coronary revascularization: A patient is deemed unsuitable for revascularization in the presence of a CAD due to 1 or several significant epicardial stenoses and/or to microvascular dysfunction where PCI or bypass surgery cannot be reasonably attempted or is not expected to improve myocardial perfusion. When appropriate, the diagnosis of coronary disease unsuitable for

Limitations of the Classification

The present phenotypic classification scheme relies exclusively on anatomical features identified on coronary angiogram. It does not take into account other clinical factors that can affect the decision to proceed with revascularization. Nonanatomical factors such as comorbidities, available local expertise, or procedural risk have been intentionally left out of the classification because they are difficult to capture, subject to personal interpretation, and affected ethnic origin. Clinically,

Conclusions

The heterogeneity of epidemiological data in RFA reflects the need for the phenotypic classification system proposed in this report. This classification system is simple but requires validation and endorsement by a scientific society before being used by clinicians and investigators. We believe that it can serve as a starting point toward a more precise understanding of the natural history of patients with RFA. Our classification may also pave the way to more comprehensive and appropriate

Funding Sources

Publication and distribution of this article are supported by Servier Canada and the Heart and Stroke Foundation of Ontario.

Disclosures

The authors have no conflicts of interest to disclose.

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