Nicorandil, Novel Potassium Adenosine Triphosphate Channel (K+ ATP) Opener in Ischemia With Non-Obstructive Coronary Arteries (INOCA) and Atherosclerotic Cardiovascular Disease (ASCVD): Delphi Consensus Statement

Background: Coronary artery disease (CAD) is a significant health concern today that has assumed epidemic proportions worldwide and in India. Objective: The pathobiology of CAD or ischemia with non-obstructive coronary arteries disease (INOCA) in most cases involves coronary microvascular dysfunction (CMD) that often requires personalized pheno-approach based on the risk stratification and diagnostic yield, especially in patients with recurrent angina episodes. Chronic therapy with anti-anginal is often fraught with challenges of unipolar action, tolerance, and oxidative stress that precludes consistent benefits in clinical cases of CMD represented by microvascular angina (MVA). To further elucidate the clinical role and relevance of long-term vasodilator therapy, including nicorandil, a Knowledge, Attitude, and Perception (KAP) survey was planned to be conducted. Methods: Based on responses to the KAP survey questionnaire, Delphi-mediated graded recommendations were developed by a specialist panel as per Agency of Health Care and Quality Systems (AHRQ) criteria. Results: Management of INOCA with MVA requires a multidisciplinary approach involving non- or invasive procedures that may be relevant for persistent or refractory angina before instituting symptomatic and long-term use of nicorandil for beta-blocker intolerant and associated clinical phenotypes. Conclusion: The analyses provide a real-life approach to the management of INOCA and angina non-obstructive coronary artery disease (ANOCA) with underlying CMD that may be relevant in outpatient settings in India.