Current Evidence-Based Treatment of Angina With Nonobstructive Coronary Arteries (ANOCA)

Although the techniques for coronary function testing (CFT) were largely developed more than 30 years ago, consensus on the specific diagnostic criteria and endotypes is still lacking. Furthermore, the management of patients with angina with nonobstructive coronary arteries (ANOCA) is challenging for most cardiologists. These patients are often a burden to the health care system due to recurrent presentations to the emergency room, repeated coronary angiography, and lack of improvement in their anginal symptoms even after being properly diagnosed with CFT. Therapies for coronary microvascular dysfunction, coronary vasospasm, and myocardial bridging have been tested in small trials and only a few randomized controlled trials. However, we are still limited in the options of therapies that we can offer to our patients. Although techniques and principles of CFT have advanced significantly, the art of managing patients with ANOCA is very challenging. A dedicated comprehensive summary of all contemporary treatment options for ANOCA is needed to guide clinicians in managing this challenging population of patients. This article subdivides ANOCA into 3 major categories: coronary microvascular dysfunction, coronary vasospasm, and myocardial bridging. Patients with ANOCA may present with 1 or a combination of the described categories. We describe major pillars in managing ANOCA patients: risk factors and lifestyle changes, traditional pharmacotherapy, device therapies, and novel approaches. We offer a summary of most evidence-based trials and scientific data on therapies for patients with ANOCA. This summary of available data about therapies aims to improve practitioners' knowledge and give more scientific merit to the care of patients with ANOCA.