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Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 November 30, 2021 e417 CLINICAL STATEMENTS AND GUIDELINES CAD, epicardial vasoconstriction was also significantly associated with higher rates of hospitalization for angina (P=0.0002).2 Prognostic evidence is available supporting the novel contribution of PET MBFR techniques; several reports also note a benefit using CMR and echocardiographic techniques. A proposed diagnostic evaluation pathway is outlined in Figure 14. Recommendation-Specific Supportive Text 1. Evidence supports a role for invasive coronary reactivity testing, including prognostic evidence from the WISE study.1,2 The CorMicA (Coronary Microvascular Angina) trial enrolled symptomatic patients (74% women) without obstructive CAD and positive invasive coronary reactivity testing (n=76 patients to intervention and 75 to the blinded control group). The intervention consisted of anti-ischemic therapy using beta-blockers and angiotensin-converting enzyme inhibitors along with preventive care (statins) and lifestyle changes, including smoking cessation, and was associated with a significant improvement in angina and quality of life over 6 months (P=0.001).4,16 This small trial did not report any differences in 6-month MACE (P=0.8). 2. PET measurement of peak myocardial blood flow and MBFR, when reduced, reflects abnormalities Figure 14. Clinical Decision Pathway for INOCA Test choice should be guided by local availability and expertise. *Ford T et al.16 †Cannot exclude microvascular vasospasm. ACh indicates acetylcholine; CAD, coronary artery disease; CFR, coronary flow reserve; CFVR, coronary flow velocity reserve; CMD, coronary microvascular dysfunction; CV, cardiovascular; FFR, fractional flow reserve; GDMT, guideline-directed medical therapy; IMR, index of microcirculatory restriction; INOCA, ischemia and no obstructive CAD; MACE, major adverse cardiovascular events; and MBFR, myocardial blood flow reserve. Downloaded from http://ahajournals.org by on October 7, 2026