Management of Coronary Endothelial Dysfunction

Diagnostic Confirmation

The American College of Cardiology recommends invasive coronary flow reserve measurement to confirm endothelial dysfunction when angiography shows normal coronaries (Class IIb recommendation) 1, 2
Provocative testing with acetylcholine during coronary angiography can serve dual purposes: excluding vasospasm and unmasking endothelial dysfunction 3
Intracoronary ultrasound or optical coherence tomography should be considered to exclude occult obstructive lesions that may be missed on standard angiography 1, 2
Avoid provocative testing in patients with significant left main disease, advanced 3-vessel disease, high-grade obstructive lesions, significant valvular stenosis, significant LV systolic dysfunction, or advanced heart failure 1, 2

The American College of Cardiology recommends beta-blockers as first-line antianginal therapy for endothelial dysfunction, targeting resting heart rate of 55-60 beats per minute 1, 2
Calcium channel blockers (CCBs) are equally first-line, either as monotherapy or combined with beta-blockers 1, 2
Long-acting nitrates are effective when combined with CCBs for symptom control 1, 2
Statins improve endothelial function and should be initiated regardless of baseline LDL levels 1

Smoking cessation is absolutely required, as smoking is the most prominent coronary risk factor and directly exacerbates coronary vasospasm 1, 5
Aggressive lipid management with statins improves endothelial function independent of LDL reduction 1
ACE inhibitors or ARBs should be initiated as baseline therapy for all patients with proven coronary microvascular disease 4
Aspirin as baseline antiplatelet therapy 4

In the absence of a culprit coronary lesion, prognosis of coronary endothelial dysfunction is generally favorable 1, 2
However, recent data indicate prognosis is not entirely benign, with 9.4% rate of death or MI by 4 years in women with no or minimal obstructive disease 7, 8

Estrogen reverses acetylcholine-induced coronary arterial vasoconstriction and reduces chest pain frequency by 50%, but is NOT recommended due to demonstrated increased cardiovascular and other risks in randomized controlled trials 1, 2, 7
Endothelial dysfunction is more common in women than men, with both typical and atypical chest pain presentations 1, 2