Cath Lab Guide to Coronary Reactivity Testing in Non‑Obstructive CAD
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Part 1 | Session 1 1. Case overview and prior workup
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Part 1 | Session 2 2. Indication and cath lab setup
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Part 1 | Session 3 3. Adenosine physiology: CFR and IMR
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Part 1 | Session 4 4. ACh protocol and spasm testing
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Part 1 | Session 5 5. Nitrates, repeat physiology and IVUS
In the final segment, Dr Jay Robert Widmer (The McKinney Heart Hospital, US) synthesises the findings: normal epicardial coronaries, normal CFR and IMR, negative acetylcholine spasm test, no significant myocardial bridge and robust vasodilator responses, all consistent with a normal coronary reactivity study.
Dr Widmer then broadens the discussion to alternative causes of chest pain in young women, including pericarditis, gastrointestinal aetiologies and musculoskeletal or neuropathic pain, and suggests further evaluation with cardiac MRI, stress CMR and targeted referrals.
The chapter closes with operator focused reflections on when and how to use invasive coronary function testing to support shared decision making and reassure patients and families.
Key learning points
- How to integrate angiography, physiology, vasoreactivity testing and IVUS into a unified conclusion in an INOCA/ANOCA case.
- Communicating a “normal” invasive coronary function result and pivoting to investigation of non-coronary chest pain aetiologies.
- Operator take aways: value of a structured 30-minute protocol, avoiding misclassification, and using these tools for patient centred care and quality assurance.
This expert level cath lab case features Dr Jay Robert Widmer (The McKinney Heart Hospital, US) demonstrating a complete invasive coronary reactivity testing protocol in a 25 year old woman with persistent chest pain, normal coronary CTA and non-obstructive findings.
Dr Widmer walks through step-by-step assessment of coronary microvascular function using thermodilution derived CFR and IMR, followed by acetylcholine-based spasm provocation, intracoronary nitrates, and adjunctive IVUS to evaluate for myocardial bridging.
Viewers will see practical discussion on access choice, wire positioning, interpretation of high flow states after nitroglycerin and adenosine, and how to integrate physiology and imaging when the epicardial coronaries are angiographically normal.
The case concludes with a structured approach to alternative diagnoses (pericarditis, non-cardiac chest pain) and how to counsel patients when invasive coronary function testing is normal.
This content is ideal for interventional cardiologists and advanced fellows managing INOCA, ANOCA, microvascular angina and vasospastic angina in a high volume cath lab setting.
This case was performed by Dr Thuy Pham Ryan and Dr Jay Robert Widmer.
Producer: Transcatheter Academy
Editor: Mirjam Boros
More from this programme
Faculty Biographies
Robert Jay Widmer
Interventional and Structural Cardiologist
Dr R Jay Widmer is an interventional and structural cardiologist and academic leader with extensive experience bridging clinical innovation and digital cardiovascular research. In 2018, he joined the Baylor Scott & White system in Temple, Texas, and now serves as Chief of Cardiology at Baylor Scott & White The Heart Group – McKinney, where he is guiding growth and development in the northeast DFW corridor. He also holds the title of Associate Professor at both Texas A&M and Baylor Colleges of Medicine. (SCAI)
Dr. Widmer completed his undergraduate degree at Southwestern University in Georgetown, Texas, before earning a combined MD/PhD from the Texas A&M Health Science Center in 2009. (SCAI) He entered the clinical research track at the Mayo Clinic in Rochester, Minnesota, and completed training in internal medicine (2012), general cardiology (2016), and interventional/structural cardiology (2018), achieving board certification in all three disciplines. (SCAI)…
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