ANOCA/INOCA/MINOCA: Open artery ischemia.

Area of Science:

• Cardiology and cardiovascular research.
• Investigating the pathophysiology of ischemic heart disease.

Background:

• Ischemic heart disease (IHD) remains a significant cause of mortality and morbidity.
• Obstructive atherosclerosis in large coronary arteries was the traditional clinical phenotype.
• Emerging evidence highlights nonobstructive coronary artery disease (CAD) as a predominant phenotype.

Purpose of the Study:

• To review syndromes of nonobstructive CAD, including angina with no obstructive CAD (ANOCA), ischemia with no obstructive CAD (INOCA), and myocardial infarction with no obstructive coronary arteries (MINOCA).
• To explore potential mechanisms and endotypes contributing to these conditions.
• To discuss biomarkers and a hypothetical management construct for these evolving syndromes.

Main Methods:

• Review of current scientific literature and evidence.
• Analysis of clinical phenotypes and their distinctions.
• Exploration of underlying mechanistic signals involving endothelium, microvasculature, and cardiomyocyte function.

Main Results:

• Nonobstructive CAD is increasingly recognized as a major clinical phenotype.
• Identified endotypes include coronary microvascular dysfunction, augmented vasoreactivity, and nonobstructive atherosclerosis.
• Phenotypic distinctions are merging with evolving methods to assess cardiomyocyte injury.

Conclusions:

• The understanding of ischemic heart disease is evolving beyond obstructive atherosclerosis.
• Coronary microvascular dysfunction and other endotypes are critical mechanistic factors.
• Biomarkers and novel management strategies are crucial for addressing nonobstructive CAD.