Endotype-guided management of ANOCA: are we ready?

Angina with non-obstructive coronary arteries (ANOCA) has emerged as one of the most challenging syndromes in contemporary cardiovascular medicine.1 Despite the absence of flow-limiting epicardial coronary stenoses, affected patients frequently experience persistent angina, recurrent healthcare resources utilisation, impaired quality of life, and a substantial psychological burden. Historically, ANOCA was often considered as “non-cardiac” chest pain or managed empirically, resulting in therapeutic uncertainty and poor symptom control. Increasing evidence now suggests that effective management of ANOCA patients depends fundamentally on accurate identification of the underlying ischaemic mechanism.123 Indeed, recent invasive physiological studies have demonstrated that ANOCA is not a single entity but rather a heterogeneous spectrum of distinct coronary disorders, with multiple identifiable endotypes.4

Contemporary guidelines now recommend invasive coronary functional testing (CFT) in persistently symptomatic patients,5 as landmark randomised trials such as CorMicA and ILIAS ANOCA have demonstrated that mechanism-guided therapy can improve angina-related quality of life.67

In this issue of EuroIntervention, the TRI-NOCA study by Farina and colleagues8 extends these observations by providing real-world multicentre evidence across a broader spectrum of haemodynamic...