This algorithm is for treatment of primary MVA. Treatment for secondary MVA (eg, related to aortic stenosis, hypertension, hypertrophic cardiomyopathy, or diastolic dysfunction) may differ according to the underlying disease. It is important to have early and ongoing discussions with patients regarding the chronic nature of angina in MVA. In the discussions, we emphasize that very few patients become completely asymptomatic with treatment. The goals of treatment are to achieve acceptable levels of angina and exercise tolerance, and to reduce long-term risk of cardiovascular disease. No large studies exist in MVA patients that provide evidence of our recommendations. Most of the treatments we are suggesting here are based on relatively small studies in MVA, extrapolation from data derived from studies in coronary artery disease-related angina (ie, ranolazine trials), and expert consensus. Refer to UpToDate content on medication administration and side effects.
The subtype of MVA related to acute precipitant is not represented in this algorithm, but in general we treat the underlying illness (eg, viral illness, post-viral syndrome, etc). Generally, this form of MVA resolves on its own once the trigger is resolved.MVA: microvascular angina; BP: blood pressure; ACE-i: angiotensin converting enzyme inhibitor; ASCVD: atherosclerotic cardiovascular disease; CT: computed tomography; PET: positron emission tomography; MRI: magnetic resonance imaging.
* Long-acting nitroglycerin in the form of a patch or pill can be added or substituted.
¶ We recommend a physical training program to improve exercise capacity and reduce angina frequency. We refer patients to cardiac rehabilitation when feasible. Otherwise we recommend regular symptom-limited exercise, with a gradual increase in duration and intensity as tolerated.
Δ Evidence of efficacy is not strong enough to recommend wide use.
◊ Refer to UpToDate content for other medications or therapies that have less evidence supporting their efficacy.
§ Diagnosis with MVA can be confirmed with intracoronary testing (eg, measurement of coronary blood flow reserve, intracoronary acetylcholine, intracoronary adenosine), or noninvasive testing (CT, PET, MRI, or echocardiographic coronary flow reserve).
¥ Refer to UpToDate content for other therapies for refractory angina that have mixed or very little supportive evidence (eg, enhanced external counter pulsation and coronary sinus reduction).