1Robert-Bosch-Krankenhaus Kardiologie und Angiologie Stuttgart, Deutschland
Background: Angina pectoris in patients without obstructive coronary artery disease (ANOCA) represents a clinical challenge, often resulting in refractory angina despite standard antianginal therapy. Currently, despite more detailed characterization of underlying mechanisms using coronary functional testing, there is no specific pharmacotherapy for microvascular angina available.
Case Summary: We present the case of a 57-year-old female patient with a history of angina pectoris (CCS class III-IV) attributable to coronary vasomotor dysfunction. Microvascular coronary spasm was confirmed through coronary angiography in 2022, including an intracoronary acetylcholine spasm provocation test. She also had single-vessel coronary artery disease with a favorable outcome following LAD stent implantation in 2014. Despite rigorous attempts at antianginal therapy, the patient experienced no relief and encountered intolerance to various medications. Notably, calcium channel blockers and nitrates elicited adverse effects such as dizziness, headaches, and nausea, while beta-blockers exacerbated symptoms. Even the second-line medication, ranolazine, was not tolerated due to the onset of double vision, an infrequent but significant side effect. The patient's profound suffering resulted in significant functional impairment and depression. There were instances when her weakness necessitated the use of a wheelchair, and at times, she struggled to complete sentences as even speaking became physically exhausting. Furthermore, all recommended therapeutic options, in line with the current ESC guidelines, were exhausted. In collaboration with the patient, a trial of the endothelin receptor antagonist bosentan was initially pursued, but this resulted in symptom exacerbation and necessitated discontinuation. In April 2023, a second individual trial of treatment was initiated, this time with vericiguat, a soluble guanylate cyclase (sGC) stimulator. The vasodilatory effects of sGC stimulators makes them promising drugs for the treatment of angina pectoris. Regular assessments during bi-weekly uptitration of vericiguat up to 10 mg daily, which included standardized questionnaires such as the Seattle Angina Questionnaire (SAQ), demonstrated a remarkable improvement in the patient's SAQ Summary Score, with an increase of nearly 25 points (baseline SAQ 20 points, after 9 weeks of vericiguat SAQ 44.7 points) as shown in figure 1. The patient reported dyspepsia as the only adverse effect, which was managed with esomeprazole. Importantly, the intensity and frequency of angina pectoris significantly reduced, enabling the patient to regain physical and functional capacity, resume daily activities, enjoy leisurely walks, engage in tandem biking with her husband, and initiate vocational reintegration.
Discussion: This case highlights the challenge of managing refractory angina in ANOCA patients and demonstrates the potential efficacy of vericiguat in microvascular spasm. The patient's substantial clinical improvement, along with vericiguat's favorable tolerability profile, make this drug a promising therapeutic option for ANOCA patients who do not respond to standard treatments. Further research and clinical trials are warranted to confirm these findings and explore the broader applicability of vericiguat in the ANOCA population.