skip to main content

ANOCA/INOCA — EECC MCQ

Instant feedback + full explanation. One question, done properly.

HardCoronary Artery DiseaseANOCA/INOCAEECC

A 60-year-old man with a history of NSTEMI 2 years ago (treated with PCI to RCA) presents with recurrent exertional angina. He is on aspirin 75 mg, bisoprolol 10 mg, ramipril 10 mg, atorvastatin 80 mg, and amlodipine 10 mg. His LDL-cholesterol is 1.8 mmol/L. Blood pressure is 124/72 mmHg, heart rate 58 bpm. He underwent a recent stress echocardiogram which shows no inducible wall motion abnormalities. CT coronary angiography shows patent RCA stent, no new obstructive disease, and coronary calcium score of 320. What is the next most appropriate step?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Refer for invasive coronary angiography with acetylcholine provocation and microvascular function testing

Explanation lettering: D = shown as A · A = shown as B · B = shown as D

This patient has persistent angina despite optimal anti-anginal therapy with no evidence of obstructive CAD on CTCA and no inducible ischaemia on stress echo. The 2024 ESC CCS Guidelines highlight the importance of investigating for ANOCA/INOCA. Invasive assessment with acetylcholine provocation (to exclude vasospasm) and coronary microvascular function testing (CFR, IMR) is recommended. Adding lipid-lowering (A) is appropriate but does not address symptoms. Ranolazine (B) and nitrates (E) are empirical without a diagnosis. Amlodipine cannot be increased beyond 10 mg (D).

Reference: ESC (2024): Guidelines for the Management of Chronic Coronary Syndromes