Episode # 32 • 21 Apr 2026
Coronary Microvascular Dysfunction: Optimizing Diagnosis & Management
Small vessels can have a major impact. Are you missing the hidden culprit of chest pain? In this episode of BackTable Cardiology, host Dr. Hady Lichaa welcomes Yale Interventional Cardiologist Dr. Samit Shah to discuss Coronary Microvascular Dysfunction (CMD) and Angina with No Obstructive Coronary Arteries (ANOCA). Their discussion demonstrates how coronary function testing turns a historically vague diagnosis into actionable phenotyping that can dramatically improve treatment efficacy and patient symptoms.
Timestamps
00:00 - Introduction
01:53 - Coronary Microvascular Dysfunction (CMD) Overview
10:55 - Cath Lab Workflow Tips
19:28 - Structural CMD: Discordant CFR and IMR Values
26:59 - Vasospastic Phenotypes
28:28 - Chest Pain Case: Syncope and Arrest Risk
33:31 - Treatment and ACh Testing
39:10 - Mixed Physiology Pharmacotherapy
49:45 - Myocardial Bridge Workup
55:19 - Workflow, Reimbursement, and Future Therapies
58:11 - Closing and Signoff
Resources
- Dr. Hady Lichaa’s Provider Profile
- Dr. Samit Shah’s Provider Profile
- COVADIS Criteria for vasospastic angina
- A doppler flow probe for canine main left coronary arteries
- ChaMP-CMD: A Phenotype-Blinded, Randomized Controlled, Cross-Over Trial
- Presence and Relevance of Myocardial Bridge in LAD-PCI of CTO and Non-CTO Lesions
- DEFINE GPS Trial
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More about this episode
Dr. Shah breaks down clinical presentations and cath lab findings of epicardial vasospasm, microvascular spasm, and endothelial dysfunction, outlining how phenotype and physiology influence treatment. He explains how to perform both Coronary Flow Reserve (CFR) and Index of Microcirculatory Resistance (IMR) testing, incorporating examples of interpretation of abnormal values. The physicians discuss COVADIS criteria for vasospastic angina, vasospasm and cardiac arrest considerations, and myocardial bridges in LAD-PCI. The episode covers door-to-discharge care for CMD: identification of phenotype via patient case walk-throughs, practical cath lab workflow, and recommendations for tailored pharmacotherapy.
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