Strengths and limitations of this study
- Qualitative interviews enabled an in-depth enquiry into the support and rehabilitation needs of people living with ischaemia with no obstructive coronary arteries.
- Inductive thematic analysis ensured descriptions and interpretations of the views of participants were grounded in the data.
- The sample included a mix of patients who had previously attended and those who had never attended cardiac rehabilitation.
- Participants were recruited primarily from online patient support forums and thus findings may not represent the views of digitally excluded patients or those not currently engaged in patient networks.
- Information about sociodemographic status and length of time since diagnosis were not collected, limiting conclusions about how these aspects might influence patients’ views.
Introduction
Ischaemia with no obstructive coronary arteries (INOCA) is an umbrella term for a range of conditions with different underlying pathologies including endothelial dysfunction, microvascular remodelling, microvascular and epicardial spasm and vasomotor abnormalities. These conditions affect up to two in five patients who present with chest pain. In contrast to obstructive coronary artery disease (CAD), where men are more likely to be affected, INOCA disproportionally affects women, particularly between the ages of 45–65. INOCA patients have been found to have more limiting dyspnoea, a comparable angina burden but reduced quality of life compared with patients with obstructive CAD.
Approximately 30% of INOCA patients report symptoms of depression and approximately 60% of patients experience chest pain. People with INOCA typically have a low peak oxygen uptake, resulting in limited functional independence, and have elevated risk of major adverse cardiovascular events and mortality. There is a clear need to develop disease-modifying treatments for microvascular and vasospastic disease in patients with INOCA.
Differences in exercise capacity and responses to medication suggest that individualised, bespoke treatments are required. The CorMicA trial found that interventional diagnostic procedures with targeted drug therapy (stratified medical therapy) led to improvements in symptoms of angina and quality of life. For some people with INOCA, stratified medical therapy included a cardiovascular prevention and rehabilitation programme (CPRP; henceforth referred to as ‘cardiac rehabilitation’).
Comprehensive cardiac rehabilitation typically includes lifestyle and risk factor management which includes exercise, diet and weight management interventions, smoking cessation, health behaviour change and education, psychosocial support and medical management. In the UK, the British Association for Cardiovascular Prevention and Rehabilitation specify which groups of people should be offered cardiac rehabilitation. Until 2023, INOCA patients were not included as the evidence of benefit was not known. Updated guidelines now recommend that people with INOCA are offered cardiac rehabilitation. However, the evidence regarding benefits remains inconclusive, and no qualitative research has previously been undertaken regarding patients’ rehabilitation needs. A crucial early step in developing appropriate, comprehensive and effective cardiac rehabilitation is to understand what those needs are and the extent to which cardiac rehabilitation in its current format can meet them.
This was an exploratory, inductive qualitative study designed to investigate the views of patients with INOCA towards cardiac rehabilitation. An inductive approach is recommended when there is little existing knowledge and the study is not based on existing theoretical frameworks or hypotheses. However, existing British Assocation for Cardiaovascular Prevention and Rehabilitation standards were used to inform the interview guide, encouraging exploration of views across all aspects of comprehensive cardiac rehabilitation content. Research questions for the study were:
- Understand the support and rehabilitation needs of people living with a confirmed or presumed diagnosis of INOCA.
- Explore which aspects of current cardiac rehabilitation could meet the needs of people with INOCA and where adjustments (if any) may be appropriate.
A secondary aim of the study was to explore the broader lived experiences of this patient group beyond cardiac rehabilitation. Participants’ accounts relating to other aspects of their lived experience generated a separate set of themes and are reported separately.
