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. 2025 Jan 6;21(1):46-57.
doi: 10.4244/EIJ-D-24-00404.

A systematic review of enrolment criteria and treatment efficacy for microvascular angina

Matthew Hammond-Haley  1 , Kayla Chiew  1 , Fiyyaz Ahmed-Jushuf  1 , Christopher A Rajkumar  1 , Michael J Foley  1 , Florentina A Simader  1 , Shayna Chotai  1 , Matthew J Shun-Shin  1 , Rasha Al-Lamee  1
Affiliations

A systematic review of enrolment criteria and treatment efficacy for microvascular angina

Matthew Hammond-Haley et al. EuroIntervention. .

Abstract

Background: Microvascular angina (MVA) is an important contributor to morbidity and mortality in patients with non-obstructive coronary artery disease. Despite improvements in its recognition and diagnosis, uncertainty remains around the most effective treatment strategy, and more data are needed.

Aims: We aimed to evaluate the quality of patient selection in treatment studies of MVA and provide a contemporary overview of the evidence base for the treatment of MVA.

Methods: PubMed, the Cochrane Library and Google Scholar were searched from inception to 4 November 2023 for all treatment studies in patients with angina and non-obstructive coronary artery disease or coronary microvascular dysfunction. Populations with acute coronary syndrome were excluded (PROSPERO: CRD42023383075).

Results: Forty-three studies were included. By contemporary definitions of MVA according to the Coronary Vasomotor Disorders International Study Group criteria, 11 (26%) studies enrolled patients with "definitive" MVA, 24 (56%) with "suspected" MVA, and 8 (19%) did not enrol patients who met the diagnostic criteria. A total of 24 unique treatment interventions were investigated. Most studies were observational and single armed (12/24, 50%) or had a single randomised study (9/24, 38%). Ranolazine is the most well-studied intervention drug. Double-blind randomised controlled trials of ranolazine (n=6) have shown inconsistent improvements in Seattle Angina Questionnaire scores and coronary flow reserve with short-term follow-up.

Conclusions: Treatment studies of MVA enrolled a heterogeneous population, with only a quarter meeting contemporary diagnostic criteria for definitive MVA. There is a paucity of high quality, randomised data to support any specific treatment intervention. Larger studies with robust selection criteria, blinded patient-reported outcomes, and long-term follow-up are needed.

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Conflict of interest statement

M. Hammond-Haley and K. Chiew are supported by the National Institute of Health and Care Research (NIHR) Academic Clinical Fellowship. F. Ahmed-Jushuf has grant support from the Medical Research Council (MRC). C.A. Rajkumar has grant support from the MRC; reports consulting fees from Philips; and speaker fees from Menarini. M.J. Foley has grant support from the MRC; and reports speaker fees from Menarini and Philips. S. Chotai has grant support from the NIHR. M.J. Shun-Shin reports consulting fees from MyCardium AI and Medtronic. R. Al-Lamee has grant support from the British Heart Foundation; reports being on a trial steering committee for Janssen Pharmaceuticals; being on an advisory board for Abbott and Philips; and reports speaker honoraria from Abbott, Philips, Medtronic, Servier, Omniprex, and Menarini. F.A. Simader has no conflicts of interest to declare.

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