Microvascular angina (cardiac syndrome X, INOCA — Ischemia with Non-Obstructive Coronary Arteries) — the chest pain from coronary microvascular dysfunction without obstructive epicardial CAD — represents a clinically important and commercially underserved angina population estimated at thirty to fifty percent of patients undergoing coronary angiography for suspected angina, with the Angina Market reflecting microvascular angina as an emerging market opportunity.

The recognition that INOCA carries significant cardiovascular event risk and substantially impairs quality of life has elevated clinical attention to this previously dismissed condition. The WISE study and subsequent ORCA and COVADIS registries demonstrating adverse cardiovascular outcomes in INOCA patients have transformed the condition from benign syndrome X to important cardiovascular risk entity requiring active management.

Coronary microvascular function testing — coronary flow reserve (CFR) measurement and microvascular resistance assessment using thermodilution or Doppler during cardiac catheterization — has become the diagnostic standard for confirming microvascular dysfunction. The CorMicA trial's randomized strategy of coronary function testing-guided therapy demonstrating superior angina outcomes versus standard care has established the diagnostic-therapeutic pathway for microvascular angina.

Treatment approaches specifically targeting microvascular dysfunction — intensive statin therapy, angiotensin-converting enzyme inhibitors, ranolazine, nitrates, and emerging endothelin antagonists — represent the pharmacological management without the clear guideline support that exists for obstructive CAD. The absence of large phase III trials for specific INOCA treatment creates the evidence gap that represents both clinical challenge and pharmaceutical research opportunity.

Do you think INOCA/microvascular angina will achieve recognition as a distinct clinical entity requiring specific diagnostic and treatment pathways in mainstream cardiology guidelines within five years?

FAQ

What is microvascular angina and how common is it? Microvascular angina (INOCA) involves chest pain from coronary microvascular dysfunction without obstructive coronary artery disease; estimated thirty to fifty percent of angina patients undergoing angiography; more common in women; previously dismissed as "syndrome X."

How is microvascular angina diagnosed? Coronary function testing during catheterization measuring coronary flow reserve (CFR) and microvascular resistance; CFR < 2.5 indicating impaired microvascular vasodilation; adenosine and acetylcholine provocation; specialized testing not performed at all centers.

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