Pacemaker-Facilitated Beta-Blocker Therapy for Symptomatic Concomitant Myocardial Bridge and Vasospastic Angina

BACKGROUND: Angina with nonobstructive coronary arteries (ANOCA) encompasses several coexisting endotypes, complicating management. CASE SUMMARY: A 56-year-old woman with chronic left bundle branch block presented with exertional angina. Coronary physiology testing suggested a hemodynamically significant left anterior descending myocardial bridge with provocable epicardial vasospasm. Nebivolol reduced angina but caused symptomatic bradycardia from sinus node dysfunction. A dual-chamber pacemaker enabled beta-blocker resumption and angina resolution. DISCUSSION: ANOCA management is challenging because its endotypes differ mechanistically; comprehensive invasive physiology testing is key to defining them. When myocardial bridging is identified, invasive assessment can help determine clinical significance. Endotype-targeted therapy likely improves outcomes, underscoring the need for endotype-specific strategies. TAKE-HOME MESSAGES: Comprehensive invasive coronary physiology testing defines coexisting ANOCA endotypes and can identify a clinically significant myocardial bridge, though diastolic fractional flow reserve may lack sensitivity and should be integrated with clinical and treatment-response findings. Permanent pacing is indicated to facilitate medical therapy in patients with chronic angina, including ANOCA.