Background: Women with signs and symptoms of myocardial ischemia often have no obstructive coronary artery disease by invasive coronary angiography compared to men. Coronary microvascular dysfunction (CMD) is thought to be a key contributory mechanism for myocardial ischemia in women with chest pain and no obstructive CAD. The CMD diagnosis is challenging, and the disease management has so far been empirical because of its multifactorial pathophysiology. Case Illustration: A 60-year-old woman with a history of hypertension and diabetes came to undergo elective diagnostic coronary angiography (DCA) related to complaints of chest pain and tightness that are often felt by patients. ECG examination shows an old myocardial anteroseptal and inferior infarction. Echocardiography examination showed left ventricular dysfunction (LVEF 26%) and right ventricular dysfunction (TAPSE 1.4 cm). From the DCA examination obtained, non-significant stenosis is 30% in mid LAD, whereas RCA, LMCA, and LCx show normal results. The patient is then discharged with optimal medical therapy advice. Discussion: Structural and functional disorders that affect the entire coronary circulation, including microcirculation, are the cause of coronary artery disease symptoms. The subset of disorders that affect the coronary microcirculation itself is called coronary microvascular dysfunction (CMD). Cardinal manifestations of CMD include angina pectoris, dyspnea on exertion, and even heart failure. Patients generally experience a combination of these symptoms. A coronary vasomotor function analysis, both non-invasive and invasive approaches, is needed to diagnose CMD. Conclusion: This case highlights the clinical importance and challenges of diagnosing CMD. In women with signs and symptoms of myocardial ischemia and no obstructive CAD, CMD may be a mechanism leading to symptoms. Therefore, it is important to identify and diagnose in the appropriate clinical setting, as CMD is associated with an increased risk of adverse cardiovascular events.

Non-obstructive coronary artery disease

Coronary microvascular dysfunction

Ischemic heart disease