Updates in the management of patients with non-obstructive coronary artery disease

A large majority (up to 70%) of patients undergoing coronary angiography because of angina and signs of myocardial ischemia do not have obstructive coronary arteries. The studies carried out in the last decades have shown that microvascular coronary dysfunction (CMD) and epicardial vasospasm are the basic pathophysiological mechanisms of non-obstructive coronary artery disease (CAD), and depending on the underlying mechanism, three clinical endotypes are differentiated: microvascular angina, vasospastic and mixed. Correct diagnosis and endotype-specific treatment of non-obstructive CAD is shown to be associated with a better quality of life and a more favorable long-term prognosis. Patients with non- obstructive CAD require a strict control of their cardiovascular risk factors. Statins and ACE inhibitors have beneficial effects in most patients. First-line anti-anginal treatment are beta-blockers and/or calcium channel blockers, depending on the underlying mechanism (microvascular or vasospastic coronary dysfunction). Second-line drugs are ivabradine, ranolazine, and nicorandil. Rho-kinase inhibitors and endothelin receptor antagonists represent potential drugs for the treatment of these patients in the future.