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This chapter discusses the pathophysiology, diagnosis, and treatment of nonobstructive atherosclerotic and nonatherosclerotic coronary heart diseases, including coronary microvascular dysfunction, epicardial coronary spasm, vasculitides, transplant vasculopathy, congenital abnormalities, and dissection and trauma (see accompanying Hurst's Central Illustration). Macrovascular diseases typically arise from pathological alterations of the intimal, medial, and/or adventitial layers of the coronary arteries, whereas microvascular disease mainly results from endothelial cell and/or vascular smooth muscle cell dysfunction. Nonobstructive coronary artery disease occurs more frequently in women than in men. Lack of available evidence means that guideline recommendations for treatments for coronary microvascular dysfunction and nonobstructive coronary artery disease are sparse; among the few recommended treatments, most have been adopted from the treatment of patients with angina pectoris related to obstructive coronary atherosclerosis. Treatment of patients with coronary spasm includes pharmacotherapy as well as elimination of risk factors. Immunomodulatory drugs are used to treat patients with vasculitides. Transplant vasculopathy has few therapeutic options, with repeat transplantation being the only definitive treatment; medical management may have some effect and percutaneous coronary intervention is an option for focal stenoses. Surgery or percutaneous interventions tend to be chosen as the treatment modality for most congenital abnormalities. Percutaneous and surgical treatments are options for dissection, but many are managed conservatively without need for revascularization.

eFig 36-01

Hurst's Central Illustration: Acute Coronary Syndromes.

Definition of acute coronary syndromes, a term that encompasses unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Diagnosis relies on integration of information from clinical history, an initial electrocardiogram (ECG), and laboratory results. Myocardial necrosis is a necessary, but not sufficient, component of NSTEMI and STEMI. CCS, Canadian Cardiovascular Society.


Coronary artery disease (CAD) accounts for 30% of all global deaths, representing the single most common cause of adult mortality and equivalent to the combined number of deaths caused by nutritional deficiencies, infectious diseases, and maternal/perinatal complications.1,2 Recent growth in the global burden of cardiovascular disease (CVD) is primary attributable to the rising incidence across low- and middle-income countries.3 Among European member states of the World Health Organization (WHO), for example, CVD death rates for men and women were highest in the Russian Federation and Uzbekistan, respectively, whereas risk was lowest in France and Israel.4 Conversely, in the United States, over 15 million Americans, or 6.2% of the adult population, have coronary heart disease (CHD), with a myocardial infarction (MI) occurring once every 43 seconds.5 Health care resource utilization as a result of CHD is significant, as over 1.1 million hospital discharges in 2010 listed MI or unstable angina (UA) as a primary or secondary diagnosis.5 Health care expenditures are also substantial; costs for MI and CHD were approximately $11 billion and $10 billion, respectively, in 2011.6 These diagnoses constitute two of the most expensive discharge ...

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