Can you get heart pain without blockages in major arteries?

Heart Pain or Angina pectoris is the pain a person feels in their chest mainly due to low blood supply to the heart muscles. The heart muscles are supplied by the coronary arteries. Two main branches of coronary arteries are left and right which would divide into major branches. The person feels heart pain when these arteries get blocked by either a thrombus or an atherosclerotic plaque. This is known as coronary artery disease.

Can you get heart pain without blockage of major arteries?

Although major coronary artery blockage is one of the main reasons for getting heart pain there are other causes too. Microvascular angina and Prinzmetal’s angina are two other forms. Microvascular angina is caused when there is poor function of tiny blood vessels nourishing the heart. This results in heart pain. Prinzmetal’s angina is caused when there is a spontaneous spasm of the vessels leading to poor blood flow.

What causes Microvascular angina?

Endothelium is the lining of microvessels. Endothelial dysfunction is considered the main cause of microvascular angina. Endothelial dysfunction is a multifactorial disorder. It is related to smoking, obesity, hypercholesterolemia, and inflammation. Also, low levels of high-density lipoprotein (HDL) are a cause. Apart from endothelial dysfunction, patients who have microvascular angina have abnormal pain perception. It is mainly due to the potassium and adenosine release which ultimately leads to abnormalities in the central pain perception.

How is Microvascular angina diagnosed?

Cardiac catheterization with coronary flow reserve (CFR) is the gold standard for diagnosing microvascular coronary disease. However, practically the diagnosis is clinical, where the patient presents with typical angina but normal epicardial arteries. Coronary flow reserve is the ratio of maximum blood flow in a coronary vessel compared to resting blood flow. In this test, a catheter is inserted into the coronary arteries and the resting blood flow is detected. Then vasodilators are given to the person to maximally dilate the coronary blood vessels. Again the coronary blood flow rate is measured which is considered the maximal blood flow. The ratio between the two values is the coronary flow reserve. In patients with microvascular angina, the coronary flow reserve is low. Non-invasive techniques such as cardiac PET, cardiac MRI, and CT scans are also reliable diagnostic tools available for diagnosis.

What are the available treatment options?

As microvascular angina is affected by various factors, lifestyle modification is important in its management. Cessation of smoking, regular exercise, dietary modification, and weight loss is advised. Managing other health conditions like high blood pressure, high blood cholesterol, and diabetes is also helpful. Pharmacological treatment can be used, which includes the use of beta-blockers, calcium channel blockers, nikorandil and nitrates. These drugs would cause dilation of coronary blood enabling a better blood supply.

The author is the Director of Cathlab and Interventional Cardiologist, Symbiosis Hospital, Mumbai. The views are personal. 

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