Endotype-informed therapy and effects on illness perception and psychological health in patients with chest pain and no obstructive coronary artery disease

AIMS: Patients with angina and no obstructive coronary artery disease (ANOCA) experience persistent symptoms, adverse illness perceptions, and psychological distress, often driven by diagnostic uncertainty. We evaluated whether non-invasive stress perfusion cardiovascular magnetic resonance (CMR), used to define ischaemic endotypes and guide targeted therapy, improves illness perception and psychological health compared with standard angiography-guided care. METHODS AND RESULTS: The Coronary microvascular angina Cardiac Magnetic Resonance imaging (CorCMR) trial was a prospective, multicentre, randomized controlled superiority trial. Patients with chest pain undergoing invasive coronary angiography showing no obstructive coronary artery disease were randomized 1:1 to CMR-guided endotype-specific management (intervention) or standard angiography-guided care (control). Illness perception was assessed using the Brief Illness Perception Questionnaire (BIPQ). Psychological health was assessed using the Patient Health Questionnaire-4 (PHQ-4). Assessments occurred at baseline, 6 months, and 12 months. A total of 250 participants were randomized (126 control, 124 intervention; mean age 63.3 years, 50.4% female). At 6 months, BIPQ scores were significantly lower in the intervention vs. control group [adjusted mean difference -8.67 (95% CI -12.04, -5.30); P < 0.001], with sustained benefit at 12 months [adjusted mean difference -10.80 (95% CI -14.27, -7.33); P < 0.001]. PHQ-4 scores were also significantly reduced at 6 months [adjusted mean difference -0.88 (95% CI -1.19, -0.57); P < 0.001] and 12 months [adjusted mean difference -0.97 (95% CI -1.29, -0.65); P < 0.001]. CONCLUSION: In patients with ANOCA, non-invasive CMR-guided endotyping linked to targeted therapy resulted in substantial and sustained improvements in illness perception and psychological health, highlighting the importance of diagnostic clarification in addressing the psychological burden of this condition.