Interventional diagnostic procedures in INOCA: an essential approach in ischemic heart disease

Approximately 60% of patients with angina symptoms do not have obstructive coronary lesions, a condition known as ischemia with non-obstructive coronary arteries (INOCA). Among these patients, coronary microvascular dysfunction (CMD) is found in nearly half. The epicardial coronary arteries represent only a small portion of the heart's vascular bed, with CMD increasingly recognized as a significant mechanism of myocardial ischemia in INOCA. Recent revisions in the Japanese and European guidelines emphasize the importance of a comprehensive functional evaluation through interventional diagnostic procedure (IDP) for diagnosing CMD and coronary vasospastic angina, two primary causes of ischemia in INOCA patients. IDP allows clinicians to identify the underlying endotype and implement tailored therapeutic strategies, moving beyond empirical therapy. Despite its clinical relevance, INOCA remains under-recognized due to a lack of awareness among healthcare providers as well as the general public, leading to diagnostic delays and undertreatment. Public education campaigns and clinician training are crucial for improving disease recognition and reducing diagnostic delay. Future directions for INOCA management include standardizing and simplifying IDP protocols, incorporating artificial intelligence for diagnostic support, and developing non-invasive alternatives for coronary functional testing. These efforts will enhance the accuracy and accessibility of IDP, facilitating its integration into routine clinical practice. Ultimately, the continued evolution of IDP will play a key role in advancing precision cardiovascular medicine, bridging the gap between symptoms, diagnosis, and meaningful care, and improving outcomes for INOCA patients.