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

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 < 2.5, hCFV ≤ 0.44 m/s independently predicted MACE (adjusted HR 6.6, p = 0.001). A combined CFVR-hCFV scheme yielded graded risk of MACE (Group A: CFVR ≥ 2.5; Group B: CFVR < 2.5 with hCFV > 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.

Keywords

angina with nonobstructive coronary arteries / coronary flow velocity reserve / coronary microvascular dysfunction / hyperemic coronary flow velocity / transthoracic Doppler echocardiography

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