Ischemia and no obstructive coronary artery disease (INOCA) is an increasingly recognized cause of angina, and it is more commonly diagnosed in women. Coronary microvascular dysfunction (CMD), or the abnormal dilation and constriction of the small vessels of the heart, is the underlying cause of INOCA in one-half of cases. This review discusses coronary microvascular pathophysiology, considerations for invasive coronary function testing and noninvasive diagnostic modalities, implications for management, and remaining knowledge gaps. KEY POINTSWomen presenting with signs and symptoms of myocardial ischemia are more likely than men to have no obstructive coronary artery disease.CMD should be considered in patients presenting with persistent angina, evidence of ischemia, and no obstructive coronary artery disease.CMD is associated with considerable risk of major adverse cardiac events including heart failure, myocardial infarction, stroke, and death.

Background Patients with stable ischemic heart disease represent a heterogeneous population at variable risk for major adverse cardiac events (MACE). Because MACE typically occurs outside the hospital, we studied whether biometric and psychometric remote patient monitoring are associated with MACE risk biomarkers. Methods and Results In 198 patients with stable ischemic heart disease (mean age 65±11 years, 60% women), we evaluated baseline measures, including biometric (FitBit 2) and psychometric (acquired via smartphone‐administered patient‐reported outcomes) remote monitoring, in the PRE‐MACE (Prediction, Risk, and Evaluation of Major Adverse Cardiac Events) study. In multivariable adjusted regression analyses, we examined the association of these measures with biomarkers of MACE risk, including NT‐proBNP (N‐terminal pro‐b‐type natriuretic peptide), u‐hs‐cTnI (ultra‐high sensitivity cardiac‐specific troponin I), and hs‐CRP (high‐sensitivity C‐reactive) protein. Both biometric and psychometric measures were associated with NT‐proBNP. Specifically, step count, heart rate, physical activity, global health score, and physical function score were all inversely related, whereas physical limitation score was directly related ( P ≤0.05 for all). However, only biometric measures (step count and heart rate) were associated with u‐hs‐cTnI (inversely related, P <0.05), while only the psychometric measures of physical limitation were associated with hs‐CRP (directly related, P ≤0.05). Conclusions In stable ischemic heart disease patients, remotely monitored measures were associated with MACE risk biomarkers. Both biometric and psychometric measures were related to NT‐proBNP. In contrast, biometric measures were uniquely related to u‐hs‐cTnI, while psychometric indices were uniquely related to hs‐CRP. Further investigation could assess the predictive value of these metrics for MACE in ischemic heart disease.

Purpose of Review-For over 20 years, the Women's Ischemia Syndrome Evaluation (WISE), a program sponsored by the National Heart, Lung, and Blood Institute, has explored diverse and important aspects of ischemic heart disease in women.Recent Findings-Women with symptoms and signs of ischemia but no significant epicardial obstructive coronary artery disease (INOCA) were documented to be at elevated risk for recurrent angina hospitalization, major adverse cardiac events, death, and health resource consumption rivaling those with obstructive coronary disease.Summary-WISE investigators have advanced our understanding of cardiovascular outcomes, systemic manifestations, psychological variables, socioeconomic factors, genetic contributions, hormonal status, advanced imaging, coronary functional findings, biomarkers, patient-reported outcomes, and treatments pertaining to women with this disease entity. This review delves into the ✉