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People with ischemic symptoms who have no angiographically obstructive coronary artery disease (CAD) are at increased risk for major adverse cardiovascular outcomes (death, myocardial infarction, stroke, and heart failure) as compared with the general population.1,2 Previous investigation, much of it originating from the National Heart, Lung, and Blood Institute–funded Women’s Ischemia Syndrome Evaluation (WISE) study, has demonstrated objective vascular abnormalities in subsets of patients with ischemic symptoms and without obstructive CAD, that is, with microvascular coronary disease. For example, invasive measurement of coronary flow reserve was abnormal in 47% of such patients, and acetylcholine induced a ≥50% reduction in blood flow in 50% and vasospasm in 5%.3 Stress imaging using any available technique demonstrates inducible ischemia in a subset of patients with symptoms and without obstructive CAD, and these patients typically have worse outcomes than those without ischemia.3–5Article see p 510Increased risk of heart failure with microvascular coronary disease is of interest for several reasons. Peripheral endothelial dysfunction has been identified in patients with heart failure with preserved ejection fraction6,7 and is a risk factor for adverse outcomes in patients with heart …

Diastolic Dysfunction in Patients With Ischemic Symptoms Without Obstructive Coronary Artery Disease