A number of pathophysiological hypotheses for MVA and HFpEF have been suggested but are not established to a degree, which would allow definition of nosological entities, stratification of affected patients, or development of effective therapeutic strategies. Despite a continuously increasing number of corresponding clinical studies, the knowledge on pathophysiological cause-effect relations involving coronary microcirculation is, however, still very limited. For MVA, clinical studies have shown a prevalence of up to 40% in patients with suspected coronary artery disease and a relevant impact on adverse cardiovascular events including cardiac death, stroke, and heart failure. The importance of coronary microcirculation for relevant pathological conditions including angina in patients with normal or near-normal coronary angiograms and heart failure with preserved ejection fraction (HFpEF) is increasingly recognized. Matching local blood supply to tissue metabolic demand entails continuous adaptation of coronary vessels via regulation of smooth muscle tone and structural dilated vessel diameter. Coronary microvascular networks play the key role in determining blood flow distribution in the heart.
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