The long and winding road to diagnosis: diagnostic delays and healthcare utilization in patients with CFT-confirmed INOCA.

BACKGROUND

Patients with Ischemia and No Obstructive Coronary Arteries (INOCA) experience recurrent angina, report reduced quality of life, and are at increased risk for major adverse cardiovascular events. Unfortunately, INOCA is often unrecognized and can be difficult to diagnose.

METHODS

We included patients with angina and INOCA diagnosed by invasive coronary function testing (CFT) and characterized their interactions with the healthcare system. Data on initial symptom onset, frequency and type of healthcare encounters, specialty referrals, diagnostic testing (including non-invasive and invasive cardiac testing, pulmonary, GI, and musculoskeletal evaluation), and medication trials for angina were abstracted from the electronic medical record.

RESULTS

We included 91 patients with INOCA who underwent CFT for determination of endotype (36% with coronary microvascular dysfunction, 35% with vasomotor disorders, 29% mixed endotype). The median time from first anginal symptom to diagnosis was 3.2 years (IQR 0.8-7.3 years), with 450 presentations to the healthcare system for angina prior to CFT. Among healthcare presentations, 72% occurred in an outpatient setting and 28% occurred in the emergency department. Each patient had a median of 3 clinic visits and 1 ED visit. A total of 225 referrals to 6 different specialties occurred, with 18% of patients seen by ≥3 cardiologists prior to diagnosis. There were 441 diagnostic tests performed for angina [median 4 (IQR 3-7) per patient], 14% of which were non-cardiac studies [median 0 (IQR 0-1) per patient]. Patients trialed a median of 2 (1-3) medications prior to diagnosis.

CONCLUSION

Many patients with INOCA experience prolonged diagnostic journeys, marked by repeated healthcare encounters, multiple specialists' visits, high testing burden, and multiple trials of medication. These findings underscore the need for earlier consideration of INOCA in the assessment of angina and more efficient diagnostic strategies.