Grasping the invisible A comprehensive approach to chronic coronary syndromes

This thesis explores how a more complete assessment of coronary physiology can improve the management of chronic coronary syndromes (CCS). Traditionally, diagnosis and treatment focused on major blockages in the large coronary arteries. However, many patients experience angina even without such obstructions. New insights show that symptoms often result from problems in both the large (epicardial) and small (microvascular) vessels of the heart.
Part B introduces a broader diagnostic strategy using coronary CT angiography (CCTA) to decide who really needs an invasive coronary angiogram (ICA). When interpreted in a wider clinical context, CCTA helps doctors tailor treatment more effectively and limit unnecessary procedures. The ILIAS ANOCA trial (Part E) tested whether performing coronary function testing (CFT) during angiography could improve care for patients with angina but no major blockages (ANOCA). The study showed that this approach is safe, practical, and significantly improves symptoms and quality of life.
Part C examines how microvascular dysfunction affects the evaluation of larger vessel disease, introducing improved methods to measure vessel resistance and blood flow. Part D focuses on diagnosing small-vessel problems, identifying two main types—structural and functional—and presenting a new, reliable index called the Microvascular Resistance Reserve (MRR).
Together, these studies highlight the importance of looking beyond visible blockages to understand the full spectrum of coronary disease. This more holistic and personalized approach can lead to better diagnosis, targeted treatment, and ultimately, improved outcomes for patients with chronic coronary syndromes.