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ANOCA/INOCA Recognition — EECC MCQ

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ModerateCoronary Artery DiseaseANOCA/INOCA RecognitionEECC

A 45-year-old woman with chest pain syndrome has normal coronary arteries on angiography and no inducible ischaemia on functional testing. She is told she has 'non-cardiac chest pain.' However, she continues to have debilitating symptoms. What diagnosis should be reconsidered?

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Correct answer: B — Microvascular angina or vasospastic angina should be reassessed with specific testing (CFR measurement, acetylcholine provocation); ANOCA/INOCA affects up to 50% of patients with stable chest pain and non-obstructive arteries

The 2024 ESC CCS Guidelines highlight that ANOCA/INOCA (angina/ischaemia with non-obstructive coronary arteries) is underdiagnosed and undertreated. Up to 50% of patients undergoing angiography for stable chest pain have non-obstructive coronary arteries, and many of these have demonstrable microvascular dysfunction or vasospasm on specific testing. Dismissing these patients as 'non-cardiac' leads to persistent symptoms, reduced quality of life, impaired work capacity, and increased healthcare utilisation. The recommended workup includes: coronary flow reserve (CFR) measurement, index of microvascular resistance (IMR), and acetylcholine provocation testing during invasive angiography. Effective treatments exist for both endotypes (microvascular angina and vasospastic angina).

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