Editing Angina (section)

===Microvascular angina in women===
Women with myocardial ischemia often have either no or atypical symptoms, such as palpitations, anxiety, weakness, and fatigue. Additionally, many females with angina are found to have cardiac ischemia, yet no evidence of obstructive coronary artery disease on cardiac catheterization. Evidence is accumulating that nearly half of females with myocardial ischemia have coronary microvascular disease, a condition often called microvascular angina (MVA). Small intramyocardial arterioles constrict in MVA causing ischemic pain that is less predictable than with typical epicardial coronary artery disease (CAD).

The pathophysiology is complex and still being elucidated, but there is strong evidence that endothelial dysfunction, decreased endogenous vasodilators, inflammation, changes in adipokines, and platelet activation are contributing factors. The diagnosis of MVA may require catheterization during which there is an assessment of the microcirculatory response to adenosine or acetylcholine and measurement of coronary and fractional flow reserve. New techniques include positron emission tomography (PET) scanning, cardiac magnetic resonance imaging (MRI), and transthoracic Doppler echocardiography.

Managing MVA can be challenging, for example, females with this condition have less coronary microvascular dilation in response to nitrates than do those without MVA. Females with MVA often have traditional risk factors for CAD such as obesity, dyslipidemia, diabetes, and hypertension. Aggressive interventions to reduce modifiable risk factors are an important component of management, especially smoking cessation, exercise, and diabetes management. The combination of non-nitrate vasodilators, such as calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors along with HMG-CoA reductase inhibitors (statins), also is effective in many women, and new drugs, such as Ranolazine and Ivabradine, have shown promise in the treatment of MVA. Other approaches include spinal cord stimulators, adenosine receptor blockade, and psychiatric intervention.<ref name="pmid27236120">{{cite journal | vauthors = Celik T, Ozturk C, Balta S, Demirkol S, Iyisoy A | title = Coronary microvascular dysfunction in patients with cardiac syndrome X: Ongoing debate | journal = International Journal of Cardiology | volume = 218 | issue = | pages = 233–234 | date = September 2016 | pmid = 27236120 | doi = 10.1016/j.ijcard.2016.05.050 }}</ref><ref name="pmid25555283">{{cite journal | vauthors = Cattaneo M, Porretta AP, Gallino A | title = Ranolazine: Drug overview and possible role in primary microvascular angina management | journal = International Journal of Cardiology | volume = 181 | issue = | pages = 376–81 | date = February 2015 | pmid = 25555283 | doi = 10.1016/j.ijcard.2014.12.055 }}</ref><ref name="pmid27245239">{{cite journal | vauthors = Lanza GA, Careri G, Stazi A, Villano A, De Vita A, Aurigemma C, Crea F | title = Clinical Spectrum and Outcome of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome and No Obstructive Coronary Atherosclerosis | journal = Circulation Journal | volume = 80 | issue = 7 | pages = 1600–6 | date = June 2016 | pmid = 27245239 | doi = 10.1253/circj.CJ-16-0145 | doi-access = free }}</ref><ref name="pmid25677893">{{cite journal | vauthors = Marinescu MA, Löffler AI, Ouellette M, Smith L, Kramer CM, Bourque JM | title = Coronary microvascular dysfunction, microvascular angina, and treatment strategies | journal = JACC. Cardiovascular Imaging | volume = 8 | issue = 2 | pages = 210–20 | date = February 2015 | pmid = 25677893 | pmc = 4384521 | doi = 10.1016/j.jcmg.2014.12.008  }}</ref><ref name="pmid27092288">{{cite journal | vauthors = Selthofer-Relatić K, Bošnjak I, Kibel A | title = Obesity Related Coronary Microvascular Dysfunction: From Basic to Clinical Practice | journal = Cardiology Research and Practice | volume = 2016 | issue = | pages = 8173816 | date = 2016 | pmid = 27092288 | pmc = 4820617 | doi = 10.1155/2016/8173816 | doi-access = free }}</ref><ref name="pmid25760881">{{cite journal | vauthors = Titterington JS, Hung OY, Wenger NK | title = Microvascular angina: an update on diagnosis and treatment | journal = Future Cardiology | volume = 11 | issue = 2 | pages = 229–42 | date = March 2015 | pmid = 25760881 | doi = 10.2217/fca.14.79 }}</ref>