Medical Management of Nonobstructive Coronary Artery Disease

Nonobstructive coronary artery disease (CAD) is increasingly recognized as a common cause of ischemic symptoms, especially in women, despite the absence of significant epicardial artery stenosis. This review summarizes the epidemiology and pathophysiology of nonobstructive CAD, encompassing entities such as angina or ischemia with nonobstructive coronary arteries and myocardial infarction with nonobstructive arteries. We discuss diagnostic approaches-including coronary angiography, coronary computed tomography angiography, and functional testing-that can uncover microvascular dysfunction or vasospasm as underlying mechanisms. Evidence-based medical management focuses on aggressive risk factor modification and symptomatic relief, mirroring guideline-directed therapies for obstructive CAD. Key interventions include antiplatelet agents, statins, angiotensin-converting enzyme inhibitors, beta blockers, and lifestyle changes, tailored to patient risk profiles. We highlight findings from recent clinical trials and studies (2020 onward) that inform management, such as the importance of stratified therapy guided by invasive physiology or advanced imaging, and discuss sex-based differences, with women disproportionately affected by nonobstructive CAD. Future directions point toward emerging therapies (eg, PCSK9 inhibitors, anti-inflammatory agents) and advanced imaging or invasive techniques to better characterize disease and personalize treatment.