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Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
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Beyond Stenosis: Mechanism-Based Multimodality Imaging and Invasive Coronary Function Testing for Endotype Definition

Lucio Giuseppe Granata1, Marcello Marchetta2, Simona Giubilato3

  • 1Cardiology Division, Garibaldi-Nesima Hospital, ARNAS Garibaldi, 95122 Catania, Italy.

Medicina (Kaunas, Lithuania)
|May 27, 2026
PubMed

Insights

Ischaemia with no obstructive coronary artery disease (INOCA) is linked to coronary vascular dysfunction. A mechanism-based diagnostic strategy using multimodality imaging and invasive testing helps define the coronary endotype for targeted therapy.

Area of Science:

  • Cardiology
  • Diagnostic Imaging
  • Vascular Medicine

Background:

  • Angina or objective myocardial ischaemia in the absence of obstructive coronary artery disease (ANOCA/INOCA) is common, causing symptoms and reduced quality of life.
  • Contemporary evidence identifies these syndromes as manifestations of coronary vascular dysfunction, including microvascular and epicardial issues.
  • Current diagnostic approaches often lack a structured, mechanism-based strategy for defining the underlying coronary endotype.

Purpose of the Study:

  • To propose a structured, mechanism-based diagnostic strategy for ANOCA/INOCA.
  • To integrate anatomical, perfusion, and functional testing for comprehensive coronary characterization.
  • To link diagnostic findings to targeted therapy through an endotype-driven approach.

Main Methods:

  • Review of contemporary evidence on coronary vascular dysfunction and diagnostic modalities.
  • Emphasis on multimodality imaging (CT angiography, PET, CMR) and invasive coronary function testing (ICFT).
  • Integration of anatomical assessment, quantitative perfusion imaging, and ICFT (coronary flow reserve, microvascular resistance, acetylcholine testing).

Main Results:

  • A shift from a stenosis-centred to a physiology- and mechanism-based approach is recommended.
  • Multimodality imaging and ICFT enable comprehensive characterization of coronary physiology and vasomotor function.
  • A pragmatic framework linking diagnostic findings to targeted therapy is proposed.

Conclusions:

  • Endotype-driven management of ANOCA/INOCA can close the gap between diagnosis and treatment.
  • A structured, mechanism-based diagnostic strategy improves patient outcomes.
  • This approach facilitates targeted therapy for ischaemia with no obstructive coronary artery disease.

Keywords:
ANOCACMRINOCAPETcoronary flow reservecoronary microvascular dysfunctioncoronary vasospasminvasive coronary function testingmultimodality imagingmyocardial blood flow

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