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Microvascular Angina Treatment — EECC MCQ

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ModerateCoronary Artery DiseaseMicrovascular Angina TreatmentEECC

A 48-year-old woman with microvascular angina (MVA) diagnosed after ANOCA workup (abnormal CFR, normal epicardial arteries) has persistent symptoms despite amlodipine and GTN. What additional pharmacological agents are recommended?

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Correct answer: C — Beta-blocker (first-line for MVA if not already tried), ranolazine, and/or nicorandil; trimetazidine and aminophylline are second-line options

The 2024 ESC CCS Guidelines provide specific recommendations for microvascular angina (MVA): (1) Beta-blockers are first-line (improving symptoms in many MVA patients via heart rate reduction and diastolic filling time); (2) Calcium channel blockers (if vasospastic component); (3) Ranolazine (reduces late sodium current, improves microvascular perfusion — the WISE study showed benefit); (4) Nicorandil (K-ATP channel opener with nitrate-like action); (5) Trimetazidine (metabolic modulator); (6) Aminophylline/theophylline (adenosine receptor antagonists — may help when adenosine-mediated pain is the mechanism). ACEi/ARBs, statins, and lifestyle modification form the background management. Nitrates alone are often insufficient as MVA involves microvascular dysfunction rather than epicardial vasospasm.

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