Introduction: Ischemia with nonobstructive coronary arteries (INOCA) is an increasingly recognized clinical syndrome. Standard modifiable cardiovascular risk factors (SMuRFs; hypertension, diabetes, hypercholesterolemia, and smoking) are associated with the development of atherosclerotic coronary artery disease, but the prevalence in INOCA is not well described. Methods: From 2017 to 2024, 221 patients with INOCA underwent invasive coronary physiologic assessment including vasoreactivity testing with acetylcholine provocation, guidewire-based assessment of coronary flow reserve (CFR), index of microcirculatory resistance (IMR), and fractional flow reserve (FFR). In our present study, we sought to examine the prevalence of SMuRFs in patients with INOCA. Results: In the entire cohort, the prevalence of SMuRFs were as follows: hypertension (63.3%), diabetes (23.1%), hypercholesterolemia (70.6%), and smoking (7.2%). 33 (14.9%) had no SMuRFs and the rest (85.1%) had at least one modifiable risk factor. SMuRF-less INOCA patients were younger (53.0 ± 11.8 years vs 58.5 ± 10.4 years; p=0.017) and were more commonly female (90.1% vs 68.1%; p=0.007). CFR, IMR and FFR were similar in both groups, but patients with SMuRFs had higher left ventricular end diastolic pressure (14.3 ± 4.7 mmHg vs 11.6 ± 3.4 mmHg; p=0.001) (Figure 1). Among patients with SMuRFs and no SMuRFs, the frequency of coronary microvascular dysfunction (CMD), vasospastic angina (VA), and mixed CMD/VA were similar, but patients with 0 SMuRFs had higher rates of myocardial bridging (21.2% vs 8.5%; p=0.044) (Figure 2). Conclusion: There was a high prevalence of SMuRFs in our study sample, with the majority of patients having hypertension and hyperlipidemia. The presence of SMuRFs was associated with left ventricular diastolic dysfunction. Among INOCA phenotypes, myocardial bridging was more common in patients without SMuRFs.
