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Patients with chest pain and unobstructed coronary arteries (INOCA) often lack a clear diagnosis and tailored therapy. In a prospective multicenter randomized trial (N = 250), adenosine stress cardiovascular magnetic resonance (CMR) with quantitative myocardial blood flow mapping (endotyping-informed strategy) revised the angiogram-based diagnosis in 53% of participants and produced a large, sustained improvement in angina (adjusted mean difference in Seattle Angina Questionnaire summary score at 12 months 20.9, 95% CI 15.8–26.0). Health-related quality of life (EQ-5D-5L) also improved (adjusted mean difference 0.09, 95% CI 0.04–0.13).
