Invasive Diagnosis of HFpEF and ANOCA in a Patient With Effort Dyspnea and Angina

Background: Angina or ischemia with nonobstructive coronary arteries (ANOCA/INOCA) and heart failure with preserved ejection fraction (HFpEF) are increasingly recognized conditions that may present with similar clinical presentation. Their underlying mechanisms and interplay remain incompletely understood. This case highlights how ANOCA/INOCA and HFpEF can coexist and be simultaneously diagnosed through a single invasive assessment. Case Summary: A 63-year-old man presented with recurrent exertional angina and dyspnea despite optimal medical therapy. Noninvasive testing and prior angiography had shown nonobstructive coronary disease. A comprehensive invasive evaluation including coronary angiography, physiology testing (adenosine and acetylcholine), and right heart catheterization was performed in a single procedure, revealing both coronary microvascular dysfunction and HFpEF. Target therapy led to symptomatic improvement. Discussion: This case illustrates the clinical overlap and potential coexistence of HFpEF and ANOCA/INOCA, emphasizing the value of integrated invasive testing to achieve accurate diagnosis and tailored treatment. Take-Home Message: A comprehensive invasive evaluation can uncover concomitant HFpEF and ANOCA/INOCA, improving diagnostic accuracy and patient outcomes.