Spasm, inflammation, coronary microcirculation and metabolism: how big is the iceberg under the stenosis

Ischemic heart disease (IHD) is a leading global cause of death and coronary artery disease has long been considered the main determinant of inducible ischemia and symptoms. However, after the performance of hundreds of thousands of percutaneous coronary revascularizations (PCI) worldwide, outcome analysis suggests that the direct relationship between chronic obstructive coronary atherosclerosis and ischemic heart disease (IHD) may represent a too simplified view of IHD; growing evidence has demonstrated the importance of a number of other underlying mechanisms. The purpose of this review is to highlight the multiple mechanisms responsible of myocardial ischemia.