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Updated: Jun 20, 2026
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Microvascular angina and the continuing dilemma of chest pain with normal coronary angiograms
1Translational Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA. cannonr@nih.gov
Insights
Chest pain without blocked arteries is common, often affecting middle-aged women. Research suggests a microvascular cause for ischemia, but the condition remains controversial.
Area of Science:
- Cardiology
- Cardiovascular Research
Background:
- Patients with angina-like chest pain and normal coronary angiograms are frequently encountered.
- This syndrome disproportionately affects women, typically aged 40-50, presenting with severe pain and variable responses to treatment.
Purpose of the Study:
- To investigate the potential association between this chest pain syndrome and myocardial ischemia.
- To explore the underlying pathophysiology, particularly microvascular dysfunction.
Main Methods:
- Review of existing literature and case reports.
- Analysis of noninvasive testing results and coronary angiography findings.
- Examination of coronary flow and metabolic responses during stress tests.
Main Results:
- Evidence suggests potential abnormalities in coronary flow and metabolism during stress, consistent with microvascular etiology.
- Some studies question the presence of ischemia, even in selected patients with abnormal noninvasive tests.
Conclusions:
- The syndrome, characterized by chest pain without obstructive coronary artery disease, likely involves microvascular dysfunction.
- Despite decades of research, the pathophysiology, diagnosis, and management of this condition remain subjects of ongoing debate and controversy.
Abstract:
Since initial reports over 4 decades ago, cases of patients with angina-like chest pain whose coronary angiograms show no evidence of obstructive coronary artery disease and who have no structural heart disease continue to be a common occurrence for cardiologists. Many features of this patient population have remained constant with successive reports over time: a female predominance, onset of symptoms commonly between 40 and 50 years of age, pain that is severe and disabling, and inconsistent responses to conventional anti-ischemic therapy. Because patients may have had abnormal noninvasive testing that led to performance of coronary angiography, investigators have sought to show an association of this syndrome with myocardial ischemia. Abnormalities in coronary flow and metabolic responses to stress have been reported by several groups, findings consistent with a microvascular etiology for ischemia and symptoms, but others have questioned the presence of ischemia, even in patients selected for abnormal noninvasive testing. Despite considerable efforts by many groups over 4 decades, the syndrome remains controversial with regard to pathophysiology, diagnosis, and management.
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