AUTHOR=Al Bitar Mohammad , Shantouf Ronney , Al Azzoni Ashraf , Al Mahmeed Wael , Atallah Bassam 

TITLE=Ischemia with no obstructed coronary arteries and microvascular testing procedures: a review of utility, pharmacotherapy, and current challenges

JOURNAL=Frontiers in Cardiovascular Medicine

VOLUME=Volume 12 - 2025

YEAR=2025

URL=https://www.frontiersin.org/journals/cardiovascular-medicine/articles/10.3389/fcvm.2025.1523352

DOI=10.3389/fcvm.2025.1523352

ISSN=2297-055X

ABSTRACT=Ischemia with no obstructive coronary arteries (INOCA) is an increasingly recognized condition in patients presenting with angina and positive stress tests but without significant coronary artery stenosis. This review addresses the pathophysiology, diagnostic approaches, and management strategies associated with INOCA, emphasizing epicardial coronary spasms and coronary microvascular dysfunction (CMD) as underlying mechanisms and myocardial bridging (MB) as a risk factor. Diagnostic modalities include both non-invasive techniques and invasive procedures, such as acetylcholine provocation testing, to differentiate vasospasm from microvascular causes. The paper discusses a potential interference between vasodilators used in trans-radial access and coronary spasm testing. Long-term management approaches for INOCA patients, including pharmacologic therapies and lifestyle interventions, are reviewed.