Beyond Stenosis: Mechanism-Based Multimodality Imaging and Invasive Coronary Function Testing for Endotype Definition...

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.