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Comprehensive Endotyping of Patients With Angina and Nonobstructive Coronary Arteries: A Report From the J-CMD

Masahiro Hada1, Tsunekazu Kakuta1, Hiroki Ueno1

  • 1Division of Cardiovascular Medicine Tsuchiura Kyodo General Hospital Ibaraki Japan.

Journal of the American Heart Association
|June 9, 2026
PubMed

Insights

Angina with nonobstructive coronary arteries (ANOCA) involves coronary vasospasm and coronary microvascular dysfunction (CMD). These conditions often coexist and show unique patterns in women versus men, highlighting the need for precise diagnosis.

Area of Science:

  • Cardiology
  • Vascular Biology
  • Diagnostic Imaging

Background:

  • Angina with nonobstructive coronary arteries (ANOCA) is often caused by coronary vasospasm and coronary microvascular dysfunction (CMD).
  • Comprehensive invasive testing is recommended for ANOCA phenotyping, but prospective data on endotype prevalence and interplay are limited.
  • This study investigates the prevalence, clinical correlations, and overlap of epicardial vasospasm, microvascular spasm, and CMD.

Purpose of the Study:

  • To determine the prevalence and clinical characteristics of epicardial vasospasm, microvascular spasm, and coronary microvascular dysfunction (CMD) in patients with ANOCA.
  • To explore the overlap between these endotypes and their associations with sex and age.
  • To provide insights into the heterogeneous pathophysiology of ANOCA.

Main Methods:

  • Analysis of data from a prospective, multicenter nationwide registry (J-CMD).
  • Standardized intracoronary functional testing in ANOCA patients, including acetylcholine-based spasm provocation and coronary flow reserve assessment.
  • Investigation of endotype distribution (epicardial vasospasm, microvascular spasm, isolated CMD, CMD with spasm) by sex and age tertiles.

Main Results:

  • Epicardial vasospasm was the most common diagnosis (44.2%), followed by microvascular spasm (16.5%), CMD with spasm (8.7%), and isolated CMD (5.0%) in 947 ANOCA patients.
  • Concurrent CMD and vasospasm were more frequent in women (10.8%) than men (6.0%).
  • Microvascular spasm was more prevalent in women, while CMD was linked to older age, female sex, hypertension, and diabetes, with age-related patterns differing between sexes.

Conclusions:

  • Coronary vasospasm and CMD are prevalent in ANOCA patients and frequently coexist.
  • Distinct sex- and age-related patterns were observed for these endotypes.
  • Comprehensive invasive assessment is crucial for precise ANOCA diagnosis and targeted therapy.
Abstract

Keywords:
angina with nonobstructive coronary arteriescoronary microvascular dysfunctioncoronary spasminvasive diagnostic procedure

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