Coronary Microvascular Dysfunction in ANOCA and INOCA: From Pathophysiological Endotypes to Precision Diagnosis and Treatment.
5 affiliations
- 1Department of Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center/North Central Bronx Hospital, New York, NY 10467, USA.
- 2Department of Internal Medicine, Cantonal Hospital "Dr. Irfan Ljubijankić", 77000 Bihac, Bosnia and Herzegovina.
- 3Department for Cardiovascular Surgery, University Clinical Center Sarajevo, 71000 Sarajevo, Bosnia and Herzegovina.
- 4Nephrology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia.
- 5Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia.
Abstract
Coronary microvascular dysfunction (CMD) is an important cause of angina and myocardial ischemia in patients without obstructive coronary artery disease and contributes substantially to the clinical spectrum of angina with non-obstructive coronary arteries (ANOCA) and ischemia with non-obstructive coronary arteries (INOCA). These conditions represent a heterogeneous group of coronary vasomotor disorders in which structural and functional abnormalities of the coronary microcirculation, endothelial dysfunction, coronary vasospasm, and diffuse non-obstructive atherosclerosis may occur alone or in combination. This review summarizes current knowledge on the pathophysiology, diagnosis, and management of CMD in patients with ANOCA and INOCA. We discuss the distinction between ANOCA and INOCA, the principal coronary functional endotypes, and the mechanisms responsible for impaired coronary microvascular function. We also review contemporary diagnostic approaches, including non-invasive imaging and invasive coronary function testing, with emphasis on their complementary roles in identifying the underlying mechanism of ischemia. Current management strategies are presented from a mechanism-based perspective, including lifestyle modification, pharmacological therapy, endotype-guided treatment, and emerging therapeutic approaches. Improved understanding of coronary functional abnormalities has shifted clinical evaluation beyond the exclusion of obstructive coronary artery disease toward identification of the mechanism responsible for persistent symptoms and ischemia. Continued advances in disease phenotyping, coronary function testing, and targeted therapies are expected to support more individualized management and improve outcomes in this diverse patient population.
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BibTeX
@article{altic2026coronary,
title = {{Coronary Microvascular Dysfunction in ANOCA and INOCA: From Pathophysiological Endotypes to Precision Diagnosis and Treatment.}},
author = {Aladin Altic and Nikola Jovanovic and Haris Džinić and Ashwin Ragupathi and Franco Joaquin Cossettini and Anida Šehanović and Marko Baralic and Aleksandar Sič},
journal = {Pathophysiology : the official journal of the International Society for Pathophysiology},
year = {2026},
month = sep,
doi = {10.3390/pathophysiology33040073},
url = {https://europepmc.org/article/MED/42924824},
note = {CC BY},
}
RIS
TY - JOUR
TI - Coronary Microvascular Dysfunction in ANOCA and INOCA: From Pathophysiological Endotypes to Precision Diagnosis and Treatment.
AU - Aladin Altic
AU - Nikola Jovanovic
AU - Haris Džinić
AU - Ashwin Ragupathi
AU - Franco Joaquin Cossettini
AU - Anida Šehanović
AU - Marko Baralic
AU - Aleksandar Sič
PY - 2026
DA - 2026/09/28
JO - Pathophysiology : the official journal of the International Society for Pathophysiology
DO - 10.3390/pathophysiology33040073
UR - https://europepmc.org/article/MED/42924824
AB - Coronary microvascular dysfunction (CMD) is an important cause of angina and myocardial ischemia in patients without obstructive coronary artery disease and contributes substantially to the clinical spectrum of angina with non-obstructive coronary arteries (ANOCA) and ischemia with non-obstructive coronary arteries (INOCA). These conditions represent a heterogeneous group of coronary vasomotor disorders in which structural and functional abnormalities of the coronary microcirculation, endothelial dysfunction, coronary vasospasm, and diffuse non-obstructive atherosclerosis may occur alone or in combination. This review summarizes current knowledge on the pathophysiology, diagnosis, and management of CMD in patients with ANOCA and INOCA. We discuss the distinction between ANOCA and INOCA, the principal coronary functional endotypes, and the mechanisms responsible for impaired coronary microvascular function. We also review contemporary diagnostic approaches, including non-invasive imaging and invasive coronary function testing, with emphasis on their complementary roles in identifying the underlying mechanism of ischemia. Current management strategies are presented from a mechanism-based perspective, including lifestyle modification, pharmacological therapy, endotype-guided treatment, and emerging therapeutic approaches. Improved understanding of coronary functional abnormalities has shifted clinical evaluation beyond the exclusion of obstructive coronary artery disease toward identification of the mechanism responsible for persistent symptoms and ischemia. Continued advances in disease phenotyping, coronary function testing, and targeted therapies are expected to support more individualized management and improve outcomes in this diverse patient population.
SN - 0928-4680
SN - 1873-149X
ER -