The Coronary Microcirculation Re-explored: Pathophysiological Insights and Clinical Implications

Coronary microvascular dysfunction (CMD) is being increasingly recognised as a significant contributor to myocardial ischaemia, particularly in patients without obstructive coronary artery disease. This review explores the anatomy and physiology of the coronary microcirculation, emphasising the role of endothelial dysfunction and endothelin-1 in CMD pathogenesis. We discuss diagnostic approaches, including invasive and non-invasive techniques, such as PET, cardiac MRI and intracoronary physiological testing. Current management strategies focus on risk factor modification and tailored pharmacotherapy, with emerging therapies targeting endothelin pathways. A comprehensive understanding of CMD is essential for improving diagnostic accuracy and developing effective treatments for patients presenting with ischaemic symptoms absent of angiographic evidence of coronary obstruction.