Angina with "Normal" Coronary Arteries

Four conditions that produce angina with a "normal" angiogram

Senior woman at doctor's office.
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In the vast majority of patients with angina, their symptoms are caused by typical coronary artery disease (CAD), in which an atherosclerotic plaque is partially obstructing a coronary artery. In these cases a stress test is likely to show evidence of a discrete blockage in one or more of the coronary arteries, and coronary angiography usually will readily identify the number and location of the obstruction or obstructions.

Indeed, angina is so closely associated with typical CAD in the minds of most patients and many doctors, that patients with apparent angina who have a “normal” angiogram are often told, in no uncertain terms, that their chest discomfort is due to something other than angina. And indeed, a number of non-cardiac conditions can produce chest discomfort.

Sometimes, however, true angina can occur in the absence of typical CAD. Sometimes patients who are experiencing angina with apparently “normal” coronary arteries actually do have a cardiac problem that needs to be diagnosed and treated.

Which Conditions Can Produce Angina With “Normal” Coronary Arteries?

Several cardiac and medical conditions can cause angina even without atherosclerotic plaques that are producing discrete blockages in the coronary arteries. Some of these conditions actually do involve the coronary arteries, while others do not.

Conditions Involving the Coronary Arteries

There are least four disorders of the coronary arteries that can cause cardiac ischemia and angina without producing blockages that can be seen on angiography. All of these conditions are more commonly seen in women, though they sometimes occur in men.

Furthermore, all four of these conditions have features that ought to alert the doctor (and the patient) that the patient's symptoms are indeed cardiac in nature, despite the ostensibly "normal" angiograms - and should lead to further evaluation and ultimately to appropriate therapy.

To read more about the characteristic features of these four conditions, click on the provided links:

Especially if you are a woman, if you are having symptoms strongly suggestive of angina, but you have been given a "clean bill of heart health" after a "normal" angiogram, you need to make sure your doctor has carefully considered each of these four conditions before pronouncing you healthy.

Conditions Not Directly Involving the Coronary Arteries

Sometimes angina can occur when portions of the heart muscle are not getting enough oxygen even though the coronary arteries themselves are completely normal.

Conditions that can produce angina without coronary artery disease include:

In general, these conditions occur in patients who are quite sick, and the angina is usually just one of an array of symptoms. So doctors taking care of these patients are not likely to be led into a false sense of complacency by the absence of classic CAD.

Sources:

Mosca, L, Manson, JE, Sutherland, SE, et al. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association. Writing Group. Circulation 1997; 96:2468.

Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:3097.

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