It is now well-recognized that chronic stable angina in its various clinical presentations (rest angina and/or exercise-related angina) can be caused by obstruction of large epicardial arteries or by non-obstructive mechanisms including coronary epicardial spasm and coronary microvascular dysfunction and these three mechanisms can coexist in the same patients; this is why angina persists in a sizable proportion of patients after successful coronary revascularization.

There is growing evidence that the prevalence of patients with ischemia and non-obstructive coronary atherosclerosis is much more than we previously believed. Indeed, about half of patients with angina and a positive stress test do not have obstructive atherosclerosis.

Similarly, the outcome of patients with ischemia and nonobstructive coronary atherosclerosis is worse than previously believed. A sizeable body of evidence nowadays substantiates how the coronary microcirculation contributes to ischemia and influences patient symptoms and outcomes.

The quality of life of patients with microcirculation disease is significantly affected, as >40% are admitted for recurrent angina. This means high healthcare costs, similar to those of obstructive diseases.

In its new 2018 Guidelines on Myocardial Revascularization, the European Society of Cardiology (ESC) recommends that for any coronary stenosis with an angiographic degree of stenosis below 90%, the presence of ischemia should be verified before any decision on revascularization is made. Relevant ischemia can be detected by noninvasive methods, such as cardiac stress test, stress echocardiography, myocardial perfusion imaging, stress magnetic resonance imaging, positron emission tomography.

Thus, in a patient with suspected angina, a diagnostic workup that comprehensively assesses both anatomic and functional alterations of coronary circulation is needed to convincingly exclude or confirm the diagnosis of angina. Overall, this Special Issue will underline that a patient with coronary artery disease should be studied by different modalities, invasive or not, to guide revascularisation and to discriminate patients at high risk of an adverse cardiovascular outcome and to understand the real mechanism of angina and, in this way, improve the prognosis of CAD patients.

Dr. Saima Mushtaq
Dr. Marco Guglielmo
Guest Editors

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• coronary artery disease
• fractional flow reserve
• angina
• microcirculation disease
• perfusion imaging
• ischemia