Coronary Microvascular Dysfunction: Bridging the Diagnosis-Treatment Divide in Women with INOCA-A Review

Coronary microvascular dysfunction (CMD) is increasingly being recognized as a significant contributor of ischemic heart disease, particularly affecting women with angina and non-obstructive coronary arteries. This contemporary review synthesizes recent landmark evidence (2022-2024) revealing a striking paradox in CMD management. While diagnostic capabilities have advanced dramatically-with CMD now identified in 41% of patients with non-obstructive coronary disease-this diagnostic success has not translated into therapeutic benefits. Recent meta-analyses demonstrate that CMD doubles cardiovascular risk (HR 2.08-2.45), yet the first randomized trial of invasive endotyping (CorCTA) found that improved diagnosis failed to improve symptoms despite a 4-fold enhancement in diagnostic accuracy. This diagnosis-treatment gap represents one of the most pressing challenges in contemporary cardiovascular medicine, reflecting fundamental failures that demand urgent reconceptualization. We examine current evidence on its prevalence, diagnostic approaches, and prognostic implications, highlighting the urgent need for CMD-specific therapies to bridge the gap between diagnostic capability and clinical outcomes. Until CMD-specific therapies emerge from dedicated research programs, clinicians must optimize available treatments while advocating for the resources and research focus this condition deserves.