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Writing Committee Members, Virani SS, Newby LK, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2023;82(9):833-955. doi:10.1016/j.jacc.2023.04.003
Hokimoto S, Kaikita K, Yasuda S, et al. JCS/CVIT/JCC 2023 Guideline Focused Update on Diagnosis and Treatment of Vasospastic Angina (Coronary Spastic Angina) and Coronary Microvascular Dysfunction. Circ J. 2023;87(6):879-936. doi:10.1253/circj.CJ-22-0779
Ford TJ, Stanley B, Sidik N, et al. 1-Year Outcomes of Angina Management Guided by Invasive Coronary Function Testing (CorMicA). JACC Cardiovasc Interv. 2020;13(1):33-45. doi:10.1016/j.jcin.2019.11.001
Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407-477. doi:10.1093/eurheartj/ehz425
Ford TJ, Stanley B, Good R, et al. Stratified Medical Therapy Using Invasive Coronary Function Testing in Angina: The CorMicA Trial. J Am Coll Cardiol. 2018;72(23 Pt A):2841-2855. doi:10.1016/j.jacc.2018.09.006
Definition and Clinical FeaturesTop
Microvascular angina refers to angina pectoris caused by coronary microvascular dysfunction in patients without significant obstructive coronary artery disease. Although previously termed cardiac syndrome X, microvascular angina is now recognized as a distinct pathophysiological entity.
Symptoms: Chest pain is typically a retrosternal heaviness, tightness, or dull ache. It may be more intense and prolonged compared with other types of angina. It usually develops on exertion or with mental stress but may also occur after exercise or at rest. The pain usually lasts >10 minutes (up to >30 minutes after the end of exertion). It responds poorly to nitroglycerin. Symptoms of anxiety disorders may occur. Acute coronary syndrome may occur despite the absence of significant epicardial artery occlusion on angiography.
DiagnosisTop
Diagnosis, according to the most stringent criteria, requires all of:
1) Symptoms related to myocardial ischemia.
2) Objective evidence of myocardial ischemia (eg, stress-induced chest pain, electrocardiographic [ECG] changes, and/or abnormal myocardial perfusion).
3) Absence of flow-limiting coronary disease (<50% stenosis or fractional low reserve >0.80).
4) Presence of coronary microvascular dysfunction (eg, intracoronary measurement of coronary flow reserve and microcirculatory resistance using specialty wires with pressure and temperature sensors, or cardiac magnetic resonance imaging [MRI]/positron emission tomography [PET] evidence of abnormal coronary flow reserve).
Invasive testing of coronary microvascular dysfunction allows assessment for concomitant spasm, which can coexist and contribute to symptoms (see Vasospastic Angina). Other causes of chest pain should be excluded (see Chest Pain).
TreatmentTop
Acetylsalicylic acid (ASA) and statins are recommended in all patients. Treatment of chest pain using beta-blockers (first-line agents), nitrates, or calcium channel blockers: see Table 3.11-13, see Table 3.11-14. In patients not responding to these agents, used either alone or in combination, administer imipramine 50 mg once daily. Some studies have reported beneficial effects of angiotensin-converting enzyme inhibitors (ACEIs), sildenafil, ranolazine, L-arginine, and metformin. Behavioral interventions and physical exercise also may be beneficial.
PrognosisTop
Prognosis is good with respect to survival and maintaining good left ventricular systolic function, but chronic symptoms affect the quality of life.
