Nonobstructive epicardial coronary artery disease: an evolving concept in need of diagnostic and therapeutic guidance

For decades, we have been treating patients presenting with angina and concerning electrocardiographic changes indicative of ischemia or injury, in whom no culprit epicardial coronary stenosis was found during diagnostic coronary angiography. Unfortunately, the clinical outcomes of these patients were not better than those with recognized obstructive coronary disease. Improvements in technology have allowed us to better characterize these patients. Consequently, an increasing number of patients with ischemia and no obstructive coronary artery disease (INOCA) or myocardial infarction in the absence of coronary artery disease (MINOCA) have now gained formal recognition and are more commonly encountered in clinical practice. Although both entities might share functional similarities at their core, they pose significant diagnostic and therapeutic challenges. Unless we become more proficient in identifying these patients, particularly those at higher risk, morbidity and mortality outcomes will not improve. Though this field remains in constant flux, data continue to become available. Therefore, we thought it would be useful to highlight important milestones that have been recognized so we can all learn about these clinical entities. Despite all the progress made regarding INOCA and MINOCA, many important knowledge gaps continue to exist. For the time being, prompt identification and early diagnosis remain crucial in managing these patients. Even though we are still not clear whether intensive medical therapy alters clinical outcomes, we remain vigilant and wait for more data.