Microvascular angina: quo tendimus?

This editorial refers to ‘Clinical characteristics and prognosis of patients with microvascular angina: an international and prospective cohort study by the Coronary Vasomotor Disorders International Study (COVADIS) Group’, by H. Shimokawa et al., http://dx.doi.org/10.1093/eurheartj/ehab282. Up to 40% of patients undergoing investigation for angina pectoris have no evidence of significant epicardial coronary disease by either elective computed tomography coronary angiography or invasive cardiac catheterization. Myocardial ischaemia can be detected in a large proportion of these patients. There is a wide spectrum of pathophysiological mechanisms that can be responsible for myocardial ischaemia in the absence of significant epicardial coronary atherosclerotic disease which can occur in different compartments of the coronary circulation.1 (Graphical abstract). However, in many cases, these are not fully appreciated or routinely pursued in clinical practice, resulting in many patients continuing to experience reduced quality of life and increased risk of adverse events. The Coronary Vasomotor Disorders International Study (COVADIS) Group was convened in 2013 to establish international standards to diagnose disorders of coronary vasomotion. The study from this group in this issue of the European Heart Journal by Shimokawa et al.2 focuses on the group of patients with microvascular angina (MVA) for whom the COVADIS group has recommended the following diagnostic criteria:3 (i) presence of symptoms suggestive of myocardial ischaemia; (ii) objective demonstration of myocardial ischaemia by functional testing; (iii) absence of obstructive epicardial coronary disease (<50% coronary diameter reduction on angiography and/or non-significant hyperaemic or non-hyperaemic wire-based pressure indices); and (iv) demonstration of reduced coronary blood flow reserve and/or inducible microvascular spasm with provocative pharmacological testing. Establishing such standardized criteria provides a framework for undertaking studies to investigate the pathophysiology, diagnosis, treatment, and prognosis of MVA.