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Review
. 2023 Aug;53(8):519-534.
doi: 10.4070/kcj.2023.0109. Epub 2023 Jun 19.

Practical Approach for Angina and Non-Obstructive Coronary Arteries: A State-of-the-Art Review

Coen K M Boerhout  1 , Marcel A M Beijk  1 , Peter Damman  2 , Jan J Piek  1 , Tim P van de Hoef  3
Affiliations
Review

Practical Approach for Angina and Non-Obstructive Coronary Arteries: A State-of-the-Art Review

Coen K M Boerhout et al. Korean Circ J. 2023 Aug.

Abstract

Anginal symptoms are frequently encountered in patients without the presence of significant obstructive coronary artery disease (CAD). It is increasingly recognized that vasomotor disorders, such as an abnormal vasodilatory capacity of the coronary microcirculation or coronary vasospasm, are the dominant pathophysiological substrate in these patients. Although the evidence with respect to angina in patients with non-obstructive coronary arteries is accumulating, the diagnosis and treatment of these patients remains challenging. In this review, we aimed to provide a comprehensive overview regarding the pathophysiological origins of angina with non-obstructive coronary arteries disorders and its diagnostic and therapeutic considerations. Hereby, we provide a practical approach for the management of patents with angina and non-obstructive CAD.

Keywords: ANOCA; Abnormal vasodilatory capacity; Coronary microvascular disease; Vasospasm.

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Conflict of interest statement

Tim P. van de Hoef has received speaker fees and institutional research grants from Abbott and Philips. Jan J. Piek has received support as consultant for Philips/Volcano, and has received institutional research grants from Philips. Peter Damman received research grants, speaker and consultancy fees from Phillips, and research grants and speaker fees from Abbot. Marcel A.M. Beijk has received an institutional research grant from Actelion Pharmaceutical B.V. Coen K.M. Boerhout reports no conflict of interest relating to this work.

Figures

Figure 1
Figure 1. Cellular processes of coronary vasodilation and vasospasm. Schematic overview of the most important pathophysiological processes of coronary vasomotor disorders and the interplay between the endothelial, VSMCs and the myocytes.
ADP = adenosine diphosphate; ATP = adenosine triphosphate; Ca = calcium; cGMP = cyclic guanosine monophosphate; eNOS = endothelial nitric oxide synthase; ET-1 = endothelin-1; Fe = iron; GTP = guanosine triphosphate; NO = nitric oxide; sGC = soluble guanylate cyclase; VSMC = vascular smooth muscle cell.
Figure 2
Figure 2. Proposed stepwise protocol for ad-hoc invasive intracoronary function testing. Overview of a stepwise protocol for the ad-hoc assessment of the coronary function, assessing the stenosis severity, endothelial-dependent and independent vasodilatory function and the presence of coronary vasospasm.
ACh = acetylcholine; CFR = coronary flow reserve; ECG = electrocardiogram; FFR = fractional flow reserve; HMR = hyperemic microvascular resistance; iFR = instantaneous wave-free ratio; IMR = index of microvascular resistance; NTG = nitroglycerine; RCA = right coronary artery.
Figure 3
Figure 3. Proposed stepwise protocol for the pharmaceutical therapy of vasomotor disorders. General overview of possible pharmaceutical options in the treatment of vasomotor disorder.
ATP = adenosine triphosphate; ACEi = angiotensin-converting enzyme inhibitor; CCB = calcium channel blocker; DHP = dihydropyridine; RAS = renin-angiotensin system.
See this image and copyright information in PMC

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