The following are key points to remember from this European Association of Percutaneous Cardiovascular Interventions (EAPCI) Expert Consensus Document on ischemia with nonobstructive coronary arteries (INOCA):

1. Angina pectoris is the most common symptom of ischemic heart disease affecting many millions of people globally. A large proportion of patients (up to 70%) undergoing coronary angiography because of angina and evidence of myocardial ischemia do not have obstructive coronary arteries but have demonstrable ischemia, i.e., INOCA.
2. INOCA is found more frequently among women (50–70%) than among men (30–50%) undergoing coronary angiography for angina. Of note, INOCA is not a benign condition and associated with comparable incidence of adverse events as well as impaired quality of life as obstructive coronary artery disease (CAD) and should be recognized as a clinically important entity in daily clinical practice.
3. Coronary microvascular dysfunction, alone or in combination with CAD, is a mechanism of myocardial ischemia and symptoms in INOCA.
4. INOCA is often not diagnosed and, therefore, no tailored therapy is prescribed for these patients whose symptoms are often dismissed or downplayed. Multiple noninvasive techniques including transthoracic Doppler echocardiography, myocardial contrast echocardiography, positron emission tomography, magnetic resonance imaging, and single-photon emission computed tomography are available to detect ischemia in INOCA.
5. Invasive strategies, using coronary angiography and an interventional diagnostic procedure consisting of a diagnostic guidewire, pressure and flow measurements, and pharmacological coronary reactivity testing in the catheterization laboratory, should be implemented to differentiate between vasospastic angina, microvascular angina, and noncardiac pain.
6. A stratified approach to the management of INOCA to address the short- and long-term prognosis in these patients is needed. This includes tailored counseling on lifestyle factors, risk factor management as per cardiovascular disease prevention guidelines, and use of pharmacotherapy to alleviate ischemia and symptoms. A current large randomized, controlled strategy trial (WARRIOR NCT03417388) is testing if all INOCA patients should be treated with angiotensin-converting enzyme inhibitors and statins.
7. For patients experiencing vasospastic angina, calcium channel blockers followed by nitrate therapy should be administered and, if still symptomatic, the use of nicorandil should be considered.
8. For patients in whom a diagnosis of microvascular angina has been established based on abnormal coronary flow reserve and/or high microcirculatory resistance (suggesting microvascular remodeling), an initial therapy with beta-blockers should be considered, followed by use of calcium channel blockers. When symptoms continue, use of nicorandil, ranolazine, and enhanced external counterpulsation (EECP) can be considered.
9. For patients in whom the diagnosis of microvascular angina is based on the presence of microvascular spasm, an initial therapy with calcium channel blockers should be considered, followed by use of ranolazine and EECP can be considered.
10. The use of low-dose tricyclic antidepressants, such as imipramine and xanthine derivatives, may be helpful to reduce the intensity of symptoms.
11. National and international scientific societies, as well as the pharmaceutical and biomedical industries need to work together and support future research to address the incomplete understanding of the pathophysiology, the lack of targeted pharmacological treatment, and the evidence-based management of patients with INOCA.
12. In addition, there is a need to create awareness of this condition through campaigns and media to ensure timely provision of care to these patients.

Clinical Topics: Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Nonstatins, Novel Agents, Statins, Mechanical Circulatory Support, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging, Chronic Angina

Keywords: Adrenergic beta-Antagonists, Angina Pectoris, Angiotensin-Converting Enzyme Inhibitors, Antidepressive Agents, Tricyclic, Calcium Channel Blockers, Cardiology Interventions, Counterpulsation, Coronary Angiography, Coronary Artery Disease, Coronary Vasospasm, Diagnostic Imaging, Echocardiography, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Magnetic Resonance Imaging, Microvascular Angina, Myocardial Ischemia, Nicorandil, Nitrates, Positron-Emission Tomography, Primary Prevention, Quality of Life, Tomography, Emission-Computed, Single-Photon

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