Korean Circ J.  2023 Aug;53(8):519-534. 10.4070/kcj.2023.0109.

Practical Approach for Angina and Non-Obstructive Coronary Arteries: A State-of-the-Art Review

• Boerhout CK
• Beijk MA
• Damman P
• Piek JJ
• Hoef TPvd

• KMID: 2545149
• DOI: http://doi.org/10.4070/kcj.2023.0109

Abstract

Anginal symptoms are frequently encountered in patients without the presence of significant obstructive coronary artery disease (CAD). It is increasingly recognized that vasomotor disorders, such as an abnormal vasodilatory capacity of the coronary microcirculation or coronary vasospasm, are the dominant pathophysiological substrate in these patients. Although the evidence with respect to angina in patients with non-obstructive coronary arteries is accumulating, the diagnosis and treatment of these patients remains challenging. In this review, we aimed to provide a comprehensive overview regarding the pathophysiological origins of angina with non-obstructive coronary arteries disorders and its diagnostic and therapeutic considerations. Hereby, we provide a practical approach for the management of patents with angina and non-obstructive CAD.

Keyword

ANOCA; Vasospasm; Abnormal vasodilatory capacity; Coronary microvascular disease

Figure

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  Figure 1 Cellular processes of coronary vasodilation and vasospasm. Schematic overview of the most important pathophysiological processes of coronary vasomotor disorders and the interplay between the endothelial, VSMCs and the myocytes.ADP = adenosine diphosphate; ATP = adenosine triphosphate; Ca = calcium; cGMP = cyclic guanosine monophosphate; eNOS = endothelial nitric oxide synthase; ET-1 = endothelin-1; Fe = iron; GTP = guanosine triphosphate; NO = nitric oxide; sGC = soluble guanylate cyclase; VSMC = vascular smooth muscle cell.

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  Figure 2 Proposed stepwise protocol for ad-hoc invasive intracoronary function testing. Overview of a stepwise protocol for the ad-hoc assessment of the coronary function, assessing the stenosis severity, endothelial-dependent and independent vasodilatory function and the presence of coronary vasospasm.ACh = acetylcholine; CFR = coronary flow reserve; ECG = electrocardiogram; FFR = fractional flow reserve; HMR = hyperemic microvascular resistance; iFR = instantaneous wave-free ratio; IMR = index of microvascular resistance; NTG = nitroglycerine; RCA = right coronary artery.

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  Figure 3 Proposed stepwise protocol for the pharmaceutical therapy of vasomotor disorders. General overview of possible pharmaceutical options in the treatment of vasomotor disorder.ATP = adenosine triphosphate; ACEi = angiotensin-converting enzyme inhibitor; CCB = calcium channel blocker; DHP = dihydropyridine; RAS = renin-angiotensin system.

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