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Updated: Jun 18, 2025
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Invasive Functional Coronary Assessment in Myocardial Ischemia with Non-Obstructive Coronary Arteries: from
Riccardo Rinaldi1, Carmine Salzillo1, Andrea Caffè1
1Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy.
Insights
Myocardial ischemia can occur without blocked arteries due to issues like coronary microvascular dysfunction. Comprehensive invasive testing is crucial for diagnosing and managing these conditions, improving patient outcomes.
Area of Science:
- Cardiology
- Vascular Medicine
Background:
- Ischemic heart disease (IHD) is often linked to obstructive coronary artery disease (OCAD).
- A significant number of patients with myocardial ischemia symptoms lack significant coronary artery stenosis.
- Alternative mechanisms like coronary microvascular dysfunction (CMD), endothelial dysfunction, and vasospasm cause ischemia without OCAD.
Purpose of the Study:
- To review pathophysiologic mechanisms of myocardial ischemia in non-obstructive coronary arteries.
- To highlight diagnostic and therapeutic implications of invasive functional evaluation.
- To discuss the role of assessing vasodilation and vasoconstriction disorders.
Main Methods:
- Review of updated evidence on pathophysiologic mechanisms.
- Focus on invasive functional evaluation during coronary angiography.
- Assessment of both vasodilation and vasoconstriction disorders.
Main Results:
- Non-obstructive coronary artery disease is a significant cause of myocardial ischemia.
- Invasive functional assessment aids in diagnosing ischemia with non-obstructive coronary arteries (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA).
- Tailored management based on comprehensive assessment improves patient symptoms and prognosis.
Conclusions:
- Myocardial ischemia can occur without obstructive coronary artery disease through various mechanisms.
- Comprehensive invasive functional assessment is vital for accurate diagnosis and management of INOCA/MINOCA.
- Further research is needed to develop targeted therapies due to limited current knowledge.
Abstract:
Despite ischemic heart disease (IHD) has been commonly identified as the consequence of obstructive coronary artery disease (OCAD), a significant percentage of patients undergoing coronary angiography because of signs and/or symptoms of myocardial ischemia do not have any significant coronary artery stenosis. Several mechanisms other than coronary atherosclerosis, including coronary microvascular dysfunction (CMD), coronary endothelial dysfunction and epicardial coronary vasospasm, can determine myocardial ischemia or even myocardial infarction in the absence of flow-limiting epicardial coronary stenosis, highlighting the need of performing adjunctive diagnostic tests at the time of coronary angiography to achieve a correct diagnosis. This review provides updated evidence of the pathophysiologic mechanisms of myocardial ischemia with non-obstructive coronary arteries, focusing on the diagnostic and therapeutic implications of performing a comprehensive invasive functional evaluation consisting of the assessment of both vasodilation and vasoconstriction disorders. Moreover, performing a comprehensive invasive functional assessment may have important prognostic and therapeutic implications both in patients presenting with myocardial ischemia with non-obstructive coronary arteries (INOCA) or myocardial infarction with non-obstructive coronary arteries (MINOCA), as the implementation of a tailored patient management demonstrated to improve patient's symptoms and prognosis. However, given the limited knowledge of myocardial ischaemia with non-obstructive coronary arteries, there are no specific therapeutic interventions for these patients, and further research is warranted aiming to elucidate the underlying mechanisms and risk factors and to develop personalized forms of treatment.
