What Is the Role of Assessing Ischemia to Optimize Therapy and Outcomes for Patients with Stable Angina and Non-obstructed Coronary Arteries?

In this review, C. Berry et al. (British Heart Foundation, Glasgow, UK) consider the definitions of angina and myocardial ischaemia. They clarify pathophysiology, focusing on the mechanistic links between myocardial ischaemia and anginal symptoms, the difference between coronary heart disease and IHD, and the relative merits of non-invasive diagnostic tests and related clinical management.
The authors make a useful focus on the definitions of the disease and the mechanisms underlying angina and Ischemia with an interesting figure showing the pathophysiology of myocardial ischemia with or without obstructive coronary arteries.
They also focus on patients with ischemia with no obstructive coronary arteries (INOCA) who may experience impaired exercise tolerance, lethargy and gastrointestinal symptoms, discussing evidence-based treatment.
Take-home message: Stratified medicine is key as well as a disease-targeted approach to therapy is needed. Most patients presenting with angina do not have obstructive CAD. If anatomical imaging with CTCA or invasive angiography is undertaken first, patients with INOCA should be considered for functional testing. This should clarify the underlying disease mechanisms enabling linked treatment decisions for personalized treatment decisions (stratified medicine).