Ischemia and no obstructive coronary arteries in patients with stable ischemic heart disease

• Published in: International journal of cardiology 2022-02, Vol.348, p.1-8
• Main Authors: Mehta, Puja K., Quesada, Odayme, Al-Badri, Ahmed, Fleg, Jerome L., Volgman, Annabelle Santos, Pepine, Carl J., Merz, C. Noel Bairey, Shaw, Leslee J.
• Format: Article
• Language: English
• Subjects: Atherosclerosis; Coronary artery disease; Coronary Artery Disease - diagnostic imaging; Coronary Artery Disease - epidemiology; Coronary Vessels - diagnostic imaging; Functional imaging; Humans; Ischemia; Ischemic heart disease; Microcirculation; Myocardial Ischemia - diagnostic imaging; Myocardial Ischemia - epidemiology; Quality of Life
• ISSN: 0167-5273; 1874-1754
• DOI: 10.1016/j.ijcard.2021.12.013

A large proportion of patients with suspected obstructive coronary artery disease (CAD) is found to have ischemia with no obstructive coronary artery disease (INOCA). Based on current evidence, these patients are at increased risk of adverse cardiovascular events, even though they have no obstructive CAD. Importantly, INOCA is associated with recurrent clinical presentations with chest pain, impaired functional capacity, reduced health-related quality of life, and high healthcare costs. Underlying coronary microvascular dysfunction (CMD), through endothelium-dependent and independent mechanisms contribute to these adverse outcomes in INOCA. While non-invasive and invasive diagnostic testing has typically focused on identification of obstructive CAD in symptomatic patients, functional testing to detect coronary epicardial and microvascular dysfunction should be considered in those with INOCA who have persistent angina. Current diagnostic methods to clarify functional abnormalities and treatment strategies for epicardial and/or microvascular dysfunction in INOCA are reviewed. •Patients with myocardial ischemia and no obstructive coronary arteries (INOCA) are at risk of major cardiovascular events.•Coronary vascular dysfunction may contribute to abnormal coronary blood flow and ischemia.•Stress testing can detect low vasodilatory reserve, but invasive testing is needed to assess coronary endothelial dysfunction.•Invasive functional coronary angiography can provide a diagnosis and guide therapeutic management.•Anti-anginal and anti-atherosclerotic medications are used to manage INOCA, while large trials of outcomes are underway.