Ischemia with No Obstructive Coronary Artery Disease (INOCA). A Review

Background: Ischemia with no obstructive coronary artery disease (INOCA) is a clinical condition characterized by myocardial ischemia in the absence of significant coronary artery stenosis. Despite the lack of major obstructive lesions, those patients often present with chest pain, making diagnosis and management a significant challenge. Material and methods: A comprehensive search strategy was designed to identify all relevant studies. The following electronic databases were searched for studies published between 2000 and 2024: PubMed, Embase, Cochrane Library and Google Scholar. Search terms included combinations of the following keywords: “Ischemia with No Obstructive Coronary Artery Disease”, “INOCA”, “Microvascular Dysfunction”, “Coronary Artery Bypass Grafting”, “Percutaneous Coronary Intervention”, “Transmyocardial Revascularization”, “Stem Cell Therapy”, “Sympathectomy” and “Surgical Treatment in INOCA” The search strategy was designed to capture studies assessing surgical treatment interventions, outcomes, and pathophysiology in INOCA. No restrictions were applied to study type, but only studies that met the inclusion criteria were selected for further review. Inclusion criteria were established as studies published in peer-reviewed journals, research focused on surgical interventions or procedures in INOCA patients, clinical trials, observational studies, case-control studies, or cohort studies. Results: This systematic review focuses on surgical treatment options for INOCA, a less explored area in clinical cardiology. Given that most patients with INOCA do not have severe obstructive coronary lesions, traditional surgical interventions such as coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are typically not recommended. However, surgical treatments may still play a role in certain subgroups of INOCA patients, particularly those with severe and persistent symptoms or underlying pathophysiological factors that do not respond adequately to pharmacological therapies. Other surgical options under investigation include Transmyocardial Revascularization (TMR) and sympathetic denervation procedures aimed at reducing coronary vasospasm. Autologous stem cell therapy is an innovative surgical approach that has shown promise in early trials, with the potential to regenerate damaged myocardial tissue and improve microvascular function. Conclusions: This review highlights the need for ongoing research and clinical trials to assess the effectiveness of surgical options in INOCA. Although current data on surgical interventions is limited, these treatments may offer hope for patients with refractory symptoms and a personalized approach to management is essential for optimal patient outcomes.