Functional coronary vascular disease: endotype-based classification, diagnosis, and targeted management

Area of Science:

• Cardiology
• Vascular Biology
• Diagnostic Imaging

Background:

• Angina and exertional dyspnea are common in coronary artery disease (CAD), often linked to obstructive epicardial lesions.
• A significant group presents with angina despite non-obstructive coronary arteries (<50%), termed ANOCA, which can progress to ischemia (INOCA) or myocardial infarction (MINOCA).
• The pathophysiology of ANOCA/INOCA is complex and often underappreciated, leading to imprecise management strategies.

Purpose of the Study:

• To elucidate the heterogeneous pathophysiology of ANOCA and INOCA.
• To outline current diagnostic approaches for endotype characterization.
• To emphasize the importance of personalized, endotype-guided management strategies.

Main Methods:

• Non-invasive testing including ECG, laboratory studies, echocardiography, and coronary CT.
• Invasive functional testing for detailed endotype characterization.
• Review of current literature on ANOCA and INOCA pathophysiology and management.

Main Results:

• ANOCA/INOCA involve diverse functional and structural coronary abnormalities, including endothelial dysfunction and microvascular dysfunction.
• Disrupted nitric oxide, adenosine, and prostacyclin signaling contribute to ischemia despite normal epicardial arteries.
• Stepwise diagnostic evaluation is essential for identifying specific endotypes.

Conclusions:

• Personalized, endotype-guided strategies are vital for managing ANOCA and INOCA.
• Integrated pharmacologic therapies (e.g., calcium channel blockers, ranolazine) and non-pharmacologic interventions (lifestyle modification, risk reduction) are key.
• Optimizing symptom control, preventing disease progression, and reducing major adverse cardiovascular events require tailored treatment approaches.