Top Things to Know: State of the Art: Evaluation & Medical Management of Non-Obstructive Coronary Artery Disease in Patients with Chest Pain
Published: November 10, 2025
Prepared by Leandro Slipczuk MD, PhD, FACC, FASPC Section Head, Clinical Cardiology Director, Advanced Cardiac Imaging Director, CV Atherosclerosis and Lipid Disorder Center Associate Professor of Medicine, Albert Einstein College of Medicine
- Up to 50% of patients with angina show non-obstructive coronary artery disease (CAD) on angiography or coronary CT angiography (CCTA). These patients are often under-recognized and under-treated.
- Non-obstructive CAD is not benign. It carries a higher risk of adverse cardiovascular (CV) events compared to patients without any CAD.
- CCTA is highly sensitive for detecting non-obstructive atherosclerosis. It enables plaque characterization and quantitative plaque assessment, which has a well-established prognostic value for predicting future CV events.
- Positron emission tomography (PET), stress cardiac magnetic resonance (CMR), and invasive coronary physiology help identify ischemia due to microvascular dysfunction or vasospasm.
- Angina with non-obstructive coronary arteries (ANOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA) represent subgroups of NOCA, including those with plaque disruption, spasm, microvascular dysfunction, and embolism.
- Intensive management of LDL cholesterol, blood pressure, and lifestyle factors is crucial for patients with high-risk non-obstructive CAD, as these interventions improve outcomes. Addressing modifiable risk factors should be prioritized in conjunction with pharmacologic therapy.
- High-risk NOCA patients benefit from intensive lipid-lowering therapy, with anti-anginal and emerging adjunct treatments tailored to the underlying mechanism. Aspirin use is considered for select individuals, while non-statin agents can be used if LDL-C goals are not met.
- Treatment for NOCA is individualized based on underlying mechanisms: calcium channel blockers and nitrates for vasospastic angina, β-blockers and ACEi/ARBs for microvascular angina, and statins or adjunct lipid-lowering therapies for endothelial dysfunction or inflammation.
- Regular follow-up is crucial for NOCA patients to monitor risk and optimize treatment, and select individuals may benefit from additional testing to assess disease progression and therapy effectiveness. Ongoing evaluation and coordinated care help ensure adherence to recommended lifestyle and medical interventions.
- NOCA is now recognized in guidelines as a distinct entity. Ongoing trials are evaluating therapies targeting microvascular dysfunction and plaque progression, which will refine future care pathways.
Citation
Slipczuk L, Blankstein R, Bucciarelli-Ducci C, Braun LT, Phillips LM, Piña P, Shaw LJ, Tamis-Holland J, Williamson E, Virani SS; on behalf of the American Heart Association Cardiac Imaging and Intervention Committee of the Council on Clinical Cardiology and Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. State of the art: evaluation and medical management of nonobstructive coronary artery disease in patients with chest pain: a scientific statement from the American Heart Association. Circulation. Published online November 10, 2025. doi: 10.1161/CIR.0000000000001394