Coronary artery disease constitutes a great burden in many countries. In many cases, the detection of coronary ischemia by non-invasive imaging may not correlate with the presence of significant coronary stenosis. Therefore, the term “Ischemia with non-obstructive coronary artery (INOCA)” has emerged. Many theories have been proposed for such a phenomenon. Coronary tortuosity (CorT) is one of these etiologies that was found to be associated with subclinical atherosclerosis and increased coronary artery calcium score. Besides, CorT is associated with the same risk factors of ischemia, such as smoking, old age, arterial hypertension and dyslipidemia. CorT was thought to be a phenomenon; however, the association of this phenomenon with multiple cardiovascular disorders augments its clinical impact. Li et al. found that Hypertensive patients with CorT have more incidence of lacunar infarct. Turgut et al. concluded that CorT might indicate impaired left ventricular relaxation. Dogdus et al. proved that CorT negatively affects left ventricular function evaluated by 3D strain parameters with considerable depression of longitudinal deformation of the myocardium.

In this study by Estrada et al., the investigators found a highly significant association between CorT and ischemia. The presence of ischemia in territories with CorT was more frequent than those without CorT (67% versus 28% (p<0.0001)) detected by myocardial perfusion imaging (MPI). This study analyzed the specific features of tortuosity concerning the presence of myocardial ischemia. They found that the number of bend angles detected in systole during coronary angiography is associated with a high risk of myocardial ischemia (p = 0.021). Some previous studies considered the geometry of CorT and suggested indices for grading such tortuosity depending mainly on the degree of angulation or bending.^–

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