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Coronary Endothelial Dysfunction: Diagnostic Necessity or Futile Effort in Patients With Non-Obstructive Angina?

Johanna McChord1, Astrid Hubert1, Leonie Saccardi1

  • 1Department of Cardiology and Angiology, Robert Bosch Hospital, Stuttgart, Germany.

Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions
|August 1, 2025
PubMed

Insights

Endothelial dysfunction (ED) is common in angina without obstructive coronary artery disease (ANOCA) but rarely isolated. Comprehensive coronary function testing should prioritize spasm and microvascular dysfunction over ED assessment.

Area of Science:

  • Cardiology
  • Vascular Biology
  • Diagnostic Imaging

Background:

  • Angina in the absence of obstructive coronary artery disease (ANOCA) is frequently associated with endothelial dysfunction (ED), coronary microvascular dysfunction (CMD), and coronary spasm.
  • Endothelial dysfunction is characterized by a limited increase in coronary blood flow (<50%) or epicardial artery narrowing in response to low-dose acetylcholine (ACh).
  • The prevalence and clinical significance of isolated ED are not well-established.

Purpose of the Study:

  • To determine the prevalence of ED in ANOCA patients.
  • To evaluate the diagnostic utility of ED assessment within comprehensive coronary function testing (CFT).

Main Methods:

  • Eighty ANOCA patients underwent invasive coronary angiography with low- and high-dose ACh testing.
  • Coronary blood flow (CBF) was measured, and quantitative coronary angiography (QCA) assessed coronary diameter.
  • Coronary microvascular dysfunction (CMD) was defined by coronary flow reserve (CFR) < 2.5 and/or hyperemic microvascular resistance (HMR) > 2.5; coronary spasm was diagnosed per COVADIS criteria.

Main Results:

  • Endothelial dysfunction (ED) was identified in 84% of patients; coronary spasm in 80%, and CMD in 45%.
  • Combined spasm and CMD testing yielded a 90% diagnostic rate, reaching 100% with ED assessment.
  • All patients without CMD or spasm exhibited ED, with only 10% having isolated ED. Notably, 27% of ED patients also had spasm at low-dose ACh.

Conclusions:

  • Endothelial dysfunction (ED) is highly prevalent in ANOCA but seldom occurs in isolation.
  • Given the significant effort for ED testing and its minimal addition to the diagnostic yield of CFT, prioritizing spasm and CMD assessment is recommended.
  • Comprehensive spasm testing is crucial, as some ED patients present with spasm even at low acetylcholine doses.
Abstract

Keywords:
ANOCACMDcoronary spasmcoronary vasomotor disorderendothelial dysfunctionmicrovascular disease

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