Angina with Non-obstructive Coronary Arteries: Diagnostic Evaluation and Endotype-guided Management

Angina with non-obstructive coronary arteries (ANOCA) is an increasingly recognized clinical syndrome characterized by angina or angina-equivalent symptoms in the absence of obstructive coronary artery disease. Ischemia with non-obstructive coronary arteries (INOCA) is a subset in which objective evidence of ischemia is demonstrated. INOCA is associated with impaired quality of life and increased risk of heart failure, major adverse cardiovascular events, and mortality, particularly among women. The primary mechanisms include coronary microvascular dysfunction and vasospastic angina. Diagnosis requires exclusion of flow-limiting coronary disease and, when available, assessment for underlying coronary vasomotor endotypes. This review summarizes the current understanding of the epidemiology, pathophysiology, diagnostic evaluation, and management of ANOCA, including INOCA where objective ischemia is demonstrated.