Small vessels, big impact: understanding women’s microvascular heart disease

Coronary microvascular dysfunction (CMD), angina with no obstructive coronary arteries (ANOCA), and ischemia with no obstructive coronary arteries (INOCA) are increasingly recognized as key contributors to ischemic heart disease in women, who often present with atypical symptoms and higher symptom burden. CMD arises from structural and functional abnormalities of the coronary microcirculation, resulting in angina, ischemia, and adverse cardiovascular outcomes despite unobstructed epicardial vessels. Accurate, mechanism-based diagnosis using invasive coronary function testing and non-invasive imaging is critical to guide targeted therapy. Management integrates pharmacologic agents with lifestyle and psychosocial interventions. Clinical trials suggest individualized therapy improves symptoms and quality of life, though reductions in major adverse cardiovascular events remain limited. Emerging strategies, including pharmacogenomic approaches, highlight the importance of precision medicine to optimize outcomes in women with CMD, INOCA, and INOCA.