Microvascular Angina and the Continuing Dilemma of Chest Pain With Normal Coronary Angiograms

Translational Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
Journal of the American College of Cardiology (Impact Factor: 16.5). 10/2009; 54(10):877-85. DOI: 10.1016/j.jacc.2009.03.080
Source: PubMed


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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    • "In up to 60% of patients undergoing coronary angiography (CAG), no significant obstructive coronary artery disease (CAD) is detected, and these patients with nonobstructive CAD are treated conservatively (Bugiardini and Bairey Merz, 2005; Cannon, 2009; Maddox et al., 2010; Vaccarino et al., 2013). Still, chest pain in patients with normal or near normal coronary arteries is prevalent and recurrent (Jespersen et al., 2013; Mommersteeg et al., 2013), related to increased clinical examinations (Beigel et al., 2013; Rossini et al., 2013), hospitalization (Rossini et al., 2013), major adverse cardiac events (Bugiardini and Bairey Merz, 2005; Jespersen et al., 2012) and mortality (Jespersen et al., 2012; Rossini et al., 2013; Sharaf et al., 2013), which requires further investigation. "
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    ABSTRACT: Patients presenting with chest pain in nonobstructive coronary artery disease (CAD, luminal narrowing <60%) are at risk for emotional distress and future events. We aimed to examine the association of personality subtypes with persistent chest pain, and investigated the potential mediating effects of negative mood states. Any chest pain in the past month was the primary outcome measure reported by 523 patients with nonobstructive CAD (mean age 61.4 years, SD = 9.4; 48% men), who participate in the TweeSteden Mild Stenosis (TWIST) observational cohort. Personality was categorized into a 'reference group', a high social inhibition ('SI only'), a high negative affectivity ('NA only') and a 'Type D' (NA and SI) group. Negative mood states included symptoms of depression and anxiety (Hospital Anxiety and Depression Scale) and cognitive and somatic depression (Beck Depression Inventory). The PROCESS macro was used to examine the relation between personality subtypes and chest pain presence, with the negative mood states as potential mediators. Persistent chest pain was present in 44% of the patients with nonobstructive CAD. Type D personality (OR = 1.91, 95% CI 1.24-2.95), but not the 'NA only' (OR = 1.48, 95% CI 0.89-2.44) or the 'SI only' (OR = 0.93, 95% CI 0.53-1.64) group was associated with chest pain, adjusted for age and sex. Negative mood states mediated the association between personality and chest pain. Type D personality, but not negative affectivity or social inhibition, was related to chest pain in nonobstructive CAD, which was mediated by negative mood states. © 2015 European Pain Federation - EFIC®
    Full-text · Article · Jun 2015 · European journal of pain (London, England)
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    • "NCCP is associated with impaired daily activities (e.g., work, walking, exercising, and housework), reduced quality of life, and increased occupational and social disability comparable to patients with CAD [17, 18]. Many patients experience worry, anxious preoccupation with heart functioning, and recurrent chest pain which results in increased health care costs due to frequent hospitalizations, emergency department visits, and cardiac catheterizations [7–9, 19]. "
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    ABSTRACT: Objective: Noncardiac chest pain (NCCP) is seen more frequently in young population and in these patients loss of function is evolving in social and professional areas. The aim of the study is to evaluate the levels of anxiety and somatic perception in patients with chest pain presenting to cardiology clinic. Methods: Fifty-one patients with noncardiac chest pain and 51 healthy controls were included in the study. All participants performed self-report based health anxiety inventory (HAI), somatosensory amplification scale (SAS), and Toronto alexithymia scale (TAS). Results: The patient group had significantly higher scores on the SAS, HAI-1, and HAI-T scales compared to controls (P < 0.001, P = 0.006, and P = 0.038, resp.). SAS, HAI-1, and HAI-T scores were significantly higher in female patients than male (P = 0.002, 0.036, and 0.039, resp.). There were significant differences in all TAS subscale scores between two groups. Patients, who had total TAS score more than 50, also presented higher levels of health anxiety (P = 0.045). Conclusions: Anxiety, somatic symptoms, and the exaggerated sense of bodily sensations are common in patients with NCCP. These patients unnecessarily occupy the cardiology outpatient clinics. These negative results can be eliminated when consultation-liaison psychiatry evaluates these patients in collaboration with cardiology departments.
    Full-text · Article · May 2014 · BioMed Research International
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    • "This, coupled with an increased association with features of the metabolic syndrome and migraine headache disease has led many to postulate the syndrome to be one of microvascular origin.19 These patients tend to have other apparent associations including strong family history of CAD and prothrombotic states.20 However, the long-term risk of adverse cardiac events in this population remains ill-defined at best and thus perpetuates the therapeutic dilemma for clinicians. "
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    ABSTRACT: Background: Patients presenting with chest pain and evidence of functional ischemia by myocardial perfusion imaging (MPI), but lacking commensurate angiographic disease pose a diagnostic and therapeutic dilemma. They are often dismissed as having ‘false-positive MPI’. Moreover, a majority of the available long-term outcome data for it has been derived from homogenous female populations. In this study, we sought to evaluate the long-term outcomes of this presentation in a multiethnic male-predominant cohort. Materials and Methods: We retrospectively identified 47 patients who presented to our institution between 2002 and 2005 with chest pain and evidence of ischemia on MPI, but with no significant angiographic disease on subsequent cardiac catheterization (cases). The occurrence of adverse cardiovascular outcomes (chest pain, congestive heart failure, acute myocardial infarction and stroke) post-index coronary angiogram was tracked. Similar data was collected for 37 patients who also presented with chest pain, but normal MPI over the same period (controls). Overall average follow-up was over 22 months. Results: Fifty-three percent (26/47) of the cases had one or more of the adverse outcomes as compared with 22% (8/37) of controls (P < 0.01). Of these, 13 (50.0%) and 3 (37.5%) were males, respectively. Conclusions: Ischemia on MPI is predictive of long-term adverse cardiovascular outcomes despite normal (‘false-negative’) coronary angiography. This appears to be gender-neutral.
    Full-text · Article · Mar 2014 · Journal of the Nigeria Medical Association
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