Endotyping-informed therapy for patients with chest pain and no obstructive coronary artery disease: a randomized trial.
Summary
In 250 patients with chest pain and unobstructed coronaries, stress CMR-guided endotyping reclassified diagnosis in 53% and substantially improved 12‑month angina and quality of life versus usual care. The trial supports mechanism-guided management for ANOCA/INOCA.
Key Findings
- Stress CMR-guided endotyping reclassified the initial angiogram-based diagnosis in 53.0% of participants.
- At 12 months, the SAQ summary score improved by an adjusted mean difference of 20.9 versus control.
- Health-related quality of life (EQ-5D-5L) improved with an adjusted mean difference of 0.09.
Clinical Implications
For patients with angina and non-obstructive coronaries, routine functional endotyping with stress CMR can guide targeted therapy and improve symptoms and quality of life; programs should implement CMR-based pathways where available.
Why It Matters
This is a multicenter randomized superiority trial demonstrating clinically meaningful patient-reported benefits from stress CMR-guided care in a prevalent and undertreated population.
Limitations
- Resource-intensive imaging may limit generalizability across centers without CMR capability
- Trial focused on symptoms and quality of life rather than hard cardiovascular events
Future Directions
Evaluate cost-effectiveness, scalability, and effects on hard outcomes; integrate endotyping with invasive coronary function testing for combined pathways.
Study Information
- Study Type
- RCT
- Research Domain
- Diagnosis/Treatment
- Evidence Level
- I - Multicenter randomized controlled superiority trial
- Study Design
- OTHER