Ischemia and no obstructive coronary arteries: a review

Ischaemia with no obstructive coronary arteries, INOCA, is a condition which contributes to cardiovascular mortality, myocardial infarction and heart failure. This condition is more common in women, and often leads to recurrent hospitalisations and a lower quality of life. Underlying factors of INOCA have been found to be coronary vascular dysfunction, either in the epicardial vessels or the smaller arteries. General risk factors of INOCA include insulin resistance, smoking, obesity and age, as well as unique sex-specific risk factors for women. These include adverse pregnancy outcomes such as gestational diabetes, as well as menopause contributing to endothelial dysfunction, relating to INOCA. There are invasive tests for diagnosing INOCA, as although non-invasive stress testing methods exist, none can reliably detect microvascular spasms or coronary endothelial dysfunction. Generally, once detected, INOCA is usually managed with anti-anginals or agents such as Ivabradine.

This review by Mehta PK et al aimed to discuss INOCA, its diagnosis and current management strategies.

Key learnings

Ischaemia with no obstructive coronary arteries is highly under-diagnosed. This appears to be due to it being a highly heterogenous condition, presenting differently in different patients. Risk stratification is needed to identify high-risk INOCA patients, and better guidelines for treatment and management of INOCA are required. Treatment of INOCA should focus on risk factor and ischaemia control, as well as improving quality of life and angina symptoms.