2026 update on the COVADIS diagnostic criteria of international standardization for microvascular angina.

Abstract

Microvascular angina, in the context of ischemia with non-obstructed coronary arteries (INOCA), is a highly prevalent clinical condition in cardiovascular medicine. Although it remains frequently underdiagnosed, clinical research and practice have made substantial progress in the last 10 years. This includes better characterisation of affected patient cohorts, new data on the prevalence of coronary vasomotor disorders and improved diagnostic assessments (non-invasive and invasive). The aim of this paper is to update our previous 2018 recommendations for the standardization of diagnostic criteria for microvascular angina. The updated COVADIS (Coronary Vasomotor Disorders Study Group) criteria focus on the following 4 criteria: (1) symptoms of myocardial ischemia; (2) non-obstructive coronary disease (stenosis <50%); (3) objective evidence of myocardial ischemia and (4) evidence of impaired coronary microvascular function. The updated criteria incorporate new suggestions for endotype definitions based on the invasive assessment of coronary physiology including coronary flow reserve and the index of microvascular resistance during pharmacological stress as well as acetylcholine testing for epicardial and/or microvascular spasm. The updated criteria should contribute to improved recognition and better management of this condition.