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ANOCA/INOCA — EECC MCQ

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HardCoronary Artery DiseaseANOCA/INOCAEECC

A 52-year-old woman is referred to the cardiology outpatient clinic with a 6-month history of exertional chest tightness and breathlessness at CCS class II. She has no conventional cardiovascular risk factors. An exercise ECG is submaximal and inconclusive. CT coronary angiography shows no obstructive coronary artery disease but a coronary artery calcium score of 0. Transthoracic echocardiography is normal. What is the most appropriate next investigation to establish the diagnosis?

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Correct answer: D — Invasive coronary angiography with acetylcholine provocation testing and coronary flow reserve measurement

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

The 2024 ESC CCS Guidelines emphasise characterising endotypes in patients with ANOCA/INOCA. This patient has typical anginal symptoms with no obstructive CAD on CTCA and a calcium score of 0, raising suspicion for coronary microvascular disease or vasospastic angina. Invasive coronary angiography with acetylcholine provocation testing (for vasospasm) and coronary flow reserve/IMR measurement (for microvascular dysfunction) is recommended for definitive endotyping (Class IIa). Stress CMR (C) may detect ischaemia but cannot distinguish between vasospasm and microvascular dysfunction. Repeat exercise ECG (B) is unlikely to yield additional information. Holter monitoring (D) is not the appropriate test. IVUS (E) assesses plaque morphology, not functional abnormalities.

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