Ischaemia with non-obstructive coronary arteries in the 2024 European Society of Cardiology guidelines for the management of chronic coronary syndromes

AIMS: Chronic coronary syndromes (CCS) occur commonly in the absence of flow-limiting epicardial coronary stenosis. Ischaemia or angina with non-obstructive coronary arteries (INOCA/ANOCA) may be caused by coronary microvascular disease, coronary artery spasm, myocardial bridging, diffuse atherosclerosis, or a combination of disorders. METHODS AND RESULTS: We highlight the new recommendations in the 2024 European Society of Cardiology (ESC) guidelines on CCS relevant to the diagnosis and management of INOCA/ANOCA. The guidelines place a new emphasis on consideration of INOCA/ANOCA early during cardiovascular risk stratification and the initial diagnostic workup for chest pain. There is a new Class I recommendation for the availability of invasive coronary function testing (CFT) at the time of initial coronary angiography, when the mechanisms of chest pain are uncertain after non-invasive testing, and in patients with established INOCA/ANOCA who have persistent symptoms and poor quality of life despite medical therapy. Once underlying disorders have been identified based on the results of invasive CFT, the ESC guidelines emphasize a patient-centred, mechanism-based approach to medical treatment of INOCA/ANOCA to improve the symptoms and quality of life. CONCLUSION: The 2024 ESC CCS guidelines provide a new vision for the diagnosis and management of ANOCA/INOCA, with an expanded role for invasive CFT and targeted medical therapy to improve symptoms and quality of life in patients with angina.