Weekly Journal Scan: Improving symptoms and quality of life with endotype-guided management of patients with angina and no obstructive coronary artery disease

This comment refers to ‘Endotyping-informed therapy for patients with chest pain and no obstructive coronary artery disease: a randomized trial’, published in Nature Medicine. https://doi.org/10.1038/s41591-025-04044-4. ANOCA and ischaemia with no obstructive coronary arteries (INOCA) are increasingly recognized as common and clinically meaningful entities rather than incidental findings at angiography.2 Contemporary registries indicate that up to 40%–50% of patients referred for coronary angiography because of stable chest pain have no flow-limiting epicardial stenosis, with a clear predominance of this diagnosis among women.2,3 Far from being benign, ANOCA and INOCA are associated with impaired functional status, recurrent hospitalization and a higher risk of major adverse cardiovascular events compared with asymptomatic individuals.4,5 Mechanistic studies have shown that coronary microvascular dysfunction, impaired vasodilator reserve and vasospastic disorders explain a substantial proportion of symptoms.6 Nevertheless, most diagnostic pathways remain anatomy-driven, and functional coronary tests are not always performed.6,7 As a result, many patients are discharged without a clear diagnosis and/or receive empiric therapy that is not tailored to the underlying pathophysiology.8