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PARIS -- Using a structured series of tests together, operators greatly improved the diagnostic accuracy of invasive coronary angiography (ICA) for people with chronic coronary syndrome (CCS), the prospective AID-ANGIO study showed.

Among people undergoing elective ICA, only 32.2% initially had their cause of myocardial ischemia identified as obstructive coronary artery disease based on that assessment alone.

With "advanced invasive diagnosis" (AID) -- additional hierarchical assessment of intermediate-grade stenosis and functional coronary tests performed at the time of ICA -- 84.2% had obstructive and/or non-obstructive mechanisms of ischemia confirmed (P<0.001), reported Adrián Jerónimo, MD, an interventional cardiology fellow at Hospital Clínico San Carlos in Madrid, at the EuroPCR annual meeting.

"We found a large discrepancy between the invasive nature of ICA and the limited amount of information it delivers in patients with CCS. The AID strategy can be safely performed at the time of ICA to identify actionable causes of myocardial ischemia in more than 80% of patients," Jerónimo said.

Based on the AID diagnostic algorithm, the study found ischemia with non-obstructive coronary arteries (INOCA) to be "highly prevalent" at 45.1%, occurring equally in patients with angiographically normal vessels and in those with functionally non-significant stenoses.

The existing literature shows that myocardial oxygen supply-demand mismatch in INOCA may be caused by coronary microvascular dysfunction, coronary vasospasm, or both. Patients may experience microvascular angina or vasospastic angina, respectively, as a result of these disorders and may be offered different frontline pharmacotherapies.

The AID-ANGIO group identified 59.9% of cases in which the AID strategy led to a change from the initial ICA-based therapeutic plan.

Jerónimo detailed the stepped components of the AID strategy that altogether added approximately 15 minutes to the initial ICA:

1. Initial ICA to diagnose severely flow-limiting stenoses (90% or greater diameter stenosis by visual assessment)
2. Fractional flow reserve/resting full-cycle ratio to assess any stenoses under 90% for physiological relevance
3. Coronary flow reserve/index of microvascular resistance assessment of any coronary microvascular disease
4. Intracoronary acetylcholine provocation test to confirm a vasomotor subtype of INOCA

Importantly, these components of AID are already endorsed by European and . For example, evaluation with fractional flow reserve and other proven nonhyperemic pressure ratios holds a strong class I endorsement for patients with chronic coronary disease, angina, and angiographically intermediate stenoses.

The present evidence suggests that these tests can be done ad hoc, provided the treating physicians and teams are prepared for them, said EuroPCR Director William Wijns, MD, PhD, of the Lambe Institute for Translational Medicine in Galway, Ireland, during a press conference.

"The impact [of the study] will be profound, because what happens normally ... is that patients will have to come back for another procedure to undergo this testing. And so that creates an extra barrier to actually reaching appropriate diagnosis," he added.

Jerónimo noted that "the learning curve [for AID] is really short. You can implement it, potentially, in 1 day as we have seen."

AID-ANGIO was a prospective single-arm study conducted at four Spanish centers. The researchers sought an all-comers population of CCS patients referred for ICA, excluding those with heart failure or severe left ventricular dysfunction. In total, there were 317 people enrolled (44% women).

The AID strategy appeared safe, given that zero deaths or heart attacks occurred among participants.

Nonetheless, Jerónimo acknowledged that more data are needed regarding how the diagnostic sequence affects clinical outcomes, quality of life, and symptoms for patients.

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