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Updated: Jun 6, 2025
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Diagnostic Yield of Comprehensive Coronary Function Testing in Patients with Angina and Unobstructed Coronary
Johanna McChord1, Astrid Hubert1, Udo Sechtem1
1Department of Cardiology and Angiology, Robert Bosch Hospital Stuttgart, Germany.
Insights
Comprehensive coronary functional testing (CFT) reveals that coronary vasomotion disorders are highly prevalent in angina with non-obstructed coronary arteries (ANOCA). Microvascular spasm is the most common finding, emphasizing the need for spasm testing in ANOCA patients.
Area of Science:
- Cardiology
- Vascular Medicine
- Diagnostic Testing
Background:
- Coronary functional disorders (CFD) are a major cause of angina in patients with non-obstructed coronary arteries (ANOCA).
- Identified endotypes include epicardial/microvascular spasm and coronary microvascular dysfunction (CMD).
- Previous studies often lacked comprehensive coronary functional testing (CFT), including spasm provocation and CMD assessment.
Purpose of the Study:
- To investigate the prevalence of CFD in ANOCA patients.
- To characterize the specific endotypes of CFD using comprehensive CFT.
Main Methods:
- Enrolled 89 ANOCA patients undergoing comprehensive CFT.
- CFT included acetylcholine (ACh) spasm provocation testing.
- Assessed coronary flow reserve (CFR) and hyperaemic microvascular resistance via Doppler.
Main Results:
- CFT detected a coronary vasomotion disorder in 91% of ANOCA patients.
- Microvascular spasm was the most frequent endotype (61%), followed by CMD (43%).
- Isolated CMD was rare (9%); most CMD patients also had coronary spasm. Low CFR correlated with high resting flow.
Conclusions:
- Comprehensive CFT has a high diagnostic yield for CFD in ANOCA.
- Coronary spasm, especially microvascular spasm, is the predominant endotype.
- Spasm testing is crucial in ANOCA as isolated CMD is uncommon.
Background:
Coronary functional disorders (CFD) are significant contributors to angina with non-obstructed coronary arteries (ANOCA). Various endotypes, such as epicardial or microvascular spasm and/or coronary microvascular dysfunction (CMD), have been identified. Previous studies have shown a high prevalence of CFD in ANOCA cases, but often lacked comprehensive coronary functional testing (CFT), which ideally includes coronary spasm provocation testing and CMD assessment. This study aims to investigate the prevalence of CFD and to characterise endotypes in ANOCA patients using comprehensive CFT.
Methods:
A total of 89 consecutive ANOCA patients (mean age 64, 69% women) who underwent comprehensive CFT were enrolled. CFT comprised acetylcholine (ACh) spasm provocation testing and assessment of coronary flow reserve (CFR) and hyperaemic microvascular resistance using Doppler technique.
Results:
CFT identified at least one coronary vasomotion disorder in 91% of patients with ANOCA. Among them, microvascular spasm was the most common endotype (61%), followed by CMD (43%). Only 9% of patients had isolated CMD with the remaining CMD patients also showing coronary spasm. Low CFR was mainly associated with high resting coronary flow rather than impaired hyperaemic flow (R -0.60, p<0.0001). Additionally, 48% of patients with microvascular spasm exhibited moderate to severe coronary tortuosity.
Conclusion:
CFT provides a high diagnostic yield of CFD in ANOCA patients. Coronary spasm, particularly microvascular spasm, is the most frequent endotype. Patients with isolated CMD are rare, highlighting the importance of spasm testing in the ANOCA population.
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