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Microvascular Dysfunction in Ischemia with No Obstructive Coronary Arteries (INOCA): Pathophysiology, Diagnosis, and

Sidhartha Senapati1, Joel Shah1, Lakshmi Kattamuri1

  • 1Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA.

Cardiovascular & Hematological Disorders Drug Targets
|May 5, 2026
PubMed

Insights

Ischemia with No Obstructive Coronary Arteries (INOCA) involves small vessel dysfunction, not main artery blockages. Identifying INOCA type with specific tests improves angina management and quality of life.

Area of Science:

  • Cardiology
  • Vascular Medicine
  • Diagnostic Imaging

Background:

  • Ischemia with No Obstructive Coronary Arteries (INOCA) presents as angina and reduced blood flow despite clear major coronary arteries.
  • This condition often stems from underlying microvascular dysfunction, inflammation, or oxidative stress.

Purpose of the Study:

  • To synthesize current understanding of Ischemia with No Obstructive Coronary Arteries (INOCA) based on recent literature.
  • To highlight diagnostic modalities and therapeutic strategies for INOCA.

Main Methods:

  • Systematic literature review of studies published between January 2018 and December 2025.
  • Inclusion of research on Coronary Flow Reserve (CFR), Index of Microcirculatory Resistance (IMR), and novel treatments for INOCA.

Main Results:

  • Coronary Microvascular Dysfunction (CMD) in INOCA can be attributed to endothelial dysfunction, inflammation, and oxidative stress.
  • Diagnostic tools include noninvasive Cardiac Magnetic Resonance (CMR) and invasive assessments like CFR < 2.5, IMR ≥ 25, and acetylcholine provocation.
  • Pharmacological treatments such as statins, ACE inhibitors/ARBs, calcium-channel blockers, trimetazidine, and ranolazine can alleviate angina and enhance quality of life.

Conclusions:

  • INOCA is characterized by small vessel abnormalities, often missed by standard angiography, necessitating specialized diagnostic approaches.
  • Utilizing tests like CFR, IMR, and acetylcholine provocation aids in accurate INOCA diagnosis and tailored treatment strategies.
  • Personalized treatment based on INOCA subtype significantly improves patient outcomes, reducing angina and enhancing quality of life.
Abstract

Keywords:
Ischemia with no obstructive coronary arteriescoronary flow reservecoronary microvascular dysfunctionendotype-guided therapy.index of microcirculatory resistancevasospastic angina

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