Patients with angina but without obstructive epicardial coronary disease still require a specific mechanistic diagnosis to enable targeted treatment. The overarching term “coronary microvascular dysfunction” (CMD) has been applied broadly – but is it correct? We present a series of case examples culminating a systematic exploration of our large clinical database to distinguish among four categories of coronary pathophysiology. First, by far the largest group of “no stenosis angina” patients exhibits subendocardial ischemia during intact flow through diffuse epicardial disease during dipyridamole vasodilator stress. Second, rare patients indeed have ischemic signs or symptoms due solely to reduced flow attributable to microvascular dysfunction but without subendocardial hypoperfusion. Third, a previously unrecognized group of patients displays significant ST-segment changes and rare angina but normal high dipyridamole induced coronary flow and intact normal subendocardial uptake, perhaps due to a stretch mechanism from hyperemia.