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Answer: The prevalence of this complex entity has gone up thanks to the better prognosis of patients with ischemic heart disease due to changes of lifestyle, drugs, and coronary interventions. Among these, surgical revascularization and, in particular, percutaneous coronary interventions increase survival in the acute coronary syndrome setting. For its diagnosis, reversible myocardial ischemia that cannot be controlled with a combination of medical therapy, angioplasty, and myocardial revascularization surgery needs to be documented first. Although it is often due to severe stenosis of epicardial coronary arteries, it can be seen in non-atherosclerotic coronary artery diseases (spasm, microvascular disease, etc.) and myocardial diseases within the heart-brain axis including myocardial metabolism, and coronary microcirculation. Also, in the perception of pain until neuromodulatory pathways that can also be therapeutic targets in this clinical condition. Therefore, obstructive coronary disease is only one of the possible phenotypes in patients (women in particular) with angina or myocardial ischemia. There is no clear evidence associated with a higher mortality rate; however, the quality of life of rehospitalized patients is worse and health costs are higher.1,2 Former studies1,3 describe a prevalence of refractory angina (RA) of 5% to 10% in patients with chronic coronary syndromes; these studies often focus on nonrevascularizable patients with angina on non-optimized antianginal drug therapy excluding patients without stenosis of epicardial coronary arteries. These studies do not report either on possible cases of RA due to coronary microvascular dysfunction that actually seem to be most of the patients with RA. Q.: Please explain to us briefly the diagnostic approach used for screening etiologies different from ischemia due to epicardial coronary artery disease such as microvascular ischemia, vasospasm or even noncardiac causes.

Debate: Refractory angina. The Reducer device as a new therapeutic approach. Perspective from the clinic