Current Medical Therapy in Epicardial and Microvascular Disease
Evidence and Gaps.
The management of chronic coronary syndromes is shifting from an obstructive to a phenotype-guided approach, encompassing INOCA, vasospastic angina, and coronary microvascular dysfunction. While foundational therapies like statins, ACE inhibitors, and SGLT2 inhibitors support vascular health, the WARRIOR trial underscores the limitations of intensive treatment in unselected INOCA patients. This review advocates for mechanism-based anti-ischemic therapy, recommending calcium channel blockers for vasospasm, beta-blockers or ranolazine for microvascular dysfunction, and cautioning against nitrates in microvascular disease. Adopting this targeted approach enables clinicians to optimize symptom control and reserve invasive interventions for appropriate phenotypes.
Summary
Management of chronic coronary syndromes has shifted from an obstructive coronary artery disease-focused model to a phenotype-guided approach that includes angina with nonobstructive coronary arteries/ ischemia with nonobstructive coronary arteries (INOCA), vasospastic angina (VSA), and coronary microvascular dysfunction (CMD). Background therapies such as statins, angiotensin-converting enzyme inhibitors, antiplatelets, and sodium-glucose cotransporter-2 inhibitor inhibitors improve vascular health, but the WARRIOR trial highlighted the limits of intensive therapy in unselected INOCA patients. Anti-ischemic treatment should be mechanism-based: calcium channel blockers for VSA, beta-blockers and ranolazine for CMD, while nitrates may worsen microvascular disease.
