Non obstructive coronary heart disease

[SJM2022]

Diagnosed with Non obstructive coronary heart disease but finding it difficult to get info on this condition other than complex medical papers and journals.

[Milkfairy Heart Star]

Hello SJM2022,

Welcome to the forum.

Non obstructive coronary artery disease NOCAD is a collection of disorders causing angina without permanent blockages to the coronary arteries.

Other terms used are Ischaemia non obstructive coronary arteries INOCA, Angina nonobstructive coronary arteries ANOCA.

The most common cause is Microvascular dysfunction causing Microvascular angina.

MVD is when the smaller blood vessels in the heart fail to dilate or stay dilated in response to extra demands like exercise.

Coronary vasospasms are the other cause , this is when the coronary arteries go into temporary transient constrictions, this tends to be in the coronary arteries leading to vasospastic angina.

Vasospastic angina is also known as Coronary artery spasms, Prinzmetal/ Variant angina.

Some people also have vasospasms in the small blood vessels too, this can be called Microvascular angina.

NOCAD is still poorly understood and the causes are complex.

There is much more awareness about Microvascular dysfunction and vasospastic angina than in the past.

I have lived with coronary vasospastic angina for nearly 10 years. I have vasospasms in my coronary arteries and smaller blood vessels.

How was your NOCAD diagnosed?

It's important to know whether you have Microvascular dysfunction or vasospastic angina as the treatment options are different.

The BHF has this information about Microvascular and vasospastic angina.

bhf.org.uk/informationsuppo...

bhf.org.uk/informationsuppo...

bhf.org.uk/informationsuppo...

[SJM2022 in reply to Milkfairy]

Many thanks - this is really useful and has provided me with more information in a few minutes than weeks of trying to find out!

I had been getting some chest discomfort and shortness of breath since the beginning of then pandemic so the doctor initially thought it either pandemic-related stress or asthma and gave me an inhaler.

When it didn't improve I went back and was sent for exercise ECG which was mainly ok but showed some anomaly right at the end of the session, so they sent me for an angiogram and put me on beta blockers straight away as a precaution.

I went for the angiogram and when the procedure was finished he told me I had non-obstructive CAD and I should stop the beta blockers and start on statins. I was happy with this as the beta blockers were causing me nightmare side effects, but it was only when I really came round from the sedation that I realised I knew nothing about the causes.

They did a pressure test during the ECG so I assume they know the extent of any narrowing? Do you think if I go back to them they could be able to tell me the specific cause?

[Milkfairy Heart Star in reply to SJM2022]

I would suggest that you ask to discuss your angiogram results with a Cardiologist who has some expertise in caring for patients with Microvascular and vasospastic angina.

During an angiogram Microvascular dysfunction can be diagnosed when the Coronary flow reserve is found to be less than 2.5.

Microvascular dysfunction and vasospastic angina are not harmless conditions and can lead to heart attacks, strokes or other heart problems if not treated appropriately.

Are you on any other medication than statins?

We can be challenging patients to care for. It takes patience and persistence to find the best combination of medication that will help you best.

[SJM2022 in reply to Milkfairy]

Many thanks - yes - I was already on Lisinopril for high BP (many years) and they put me on aspirin after the ECG and I have been advised to keep taking these two in addition to stopping beta blockers and starting statins.

[Milkfairy Heart Star in reply to SJM2022]

I would still recommend getting further clarification of your diagnosis.

My diagnosis is coronary vasospastic angina, which is a type of Non obstructive coronary artery disease.

NOCAD isn't really a diagnosis more an umbrella term.

Are you still experiencing symptoms?

[SJM2022 in reply to Milkfairy]

Yes - still getting mild tightness and palpitations

[Milkfairy Heart Star in reply to SJM2022]

Perhaps keep a diary of your symptoms. Then assess if your present medication is enough to manage your symptoms.

Also perhaps try and spot your triggers.

Common ones are the cold, emotional and mental stress.

Extreme tiredness.

As I have vasospastic angina, I experience most of my pain at rest in the night.

Exercise is really important too.

However you may find you need a very long slow warm up followed by a long cool down afterwards.

Try not to over do it.

Microvascular and vasospastic angina has a habit of being unpredictable. Sometimes I will have a really bad episode of chest pain without rhyme or reason.

You might find this website helpful, it was written by 4 patients with over 50 years combined experience of living with Microvascular and vasospastic angina.

internationalheartspasmsall...

[SJM2022 in reply to Milkfairy]

May thanks - good advice - the web links are good too

[thehypnotist in reply to SJM2022]

I always request a copy of the examination results sent to me as well as my Gp. They should ask you, but if not you can request it from your GP. That way if you want to ask questions you can be quite specific and they don’t mind as you become an expert patient which the NHS encourages 😊

[Sootycat in reply to Milkfairy]

Same here. Thank you so much 😀

[Hidden]

I too have nocad (micro vascular angina) only mild tho but regularly get chest pains out of the blue, sometimes 12 or more times a day some days none. I find it totally random sometimes wakes me up, sometimes after exercise ,sometimes after a gentle walk.just needs to remind me it’s still there I think best person on here with the advice has already replied milkfairy is the bee’s knee’s. You won’t go far wrong taking notice of her 🙂

[SJM2022 in reply to Hidden]

Many thanks - this is really useful

[Hidden in reply to SJM2022]

Ps as to medication I am currently on statins clopidegrel as I had a stent in February and aspirin a and also amlopodine a calcium blocker.As I also have Crohn’s they don’t want to give me beta blockers as they either interfere with it or the azathioprine I take for that (quite a nasty drug itself lol only one I ever had that comes with a red warning label!) can’t get it from pharmacy have to get it from hospital 🤷‍♂️ They were going to prescribe me nitrates but they give me bad migraines (is there a good one?) so as mine is not too bad at mo they letting them slide 🙂 and finally the gtn spray which I can use if it’s a bad day! Tho been told if use it 3 times and it doesn’t settle then 999 so far only happened once and then it settled in a&e typical lol. So as milkfairy said we are challenging patients as it seems to affect peeps different and at least in my case very randomly very annoying lol

[Hidden]

Dear SJM2022

Just a big hello from me I’m afraid.

Also just wanted you to realise that, even though I cannot answer your question, I understand the worry that you have in posting it.

Take care and I hope the answers are here for you

[jerry12953]

I have not been officially diagnosed with MVA but it seems likely that is the condition I have - chest pain on exertion, for example when walking up hill. I have had several tests, (but not an angiogram,) which found no significant blockages in my main arteries. The symptoms vary quite a bit, I can do the same walk one day and get quite bad pain, then another day virtually no pain at all! At first I was prescribed low dose aspirin, bisoprolol and atorvastatin. The little bottle of nitrate they gave me didn't seem to have any effect.

I reacted badly to the bisoprolol so that was changed to amlodipine.

Earlier this year I had routine follow-up with a cardiologist who doubled my dose of statin (without knowing what my cholesterol level was) and completely disregarded my suggestion of MVA. Basically she just added more medication to my treatment! As a result I asked to see someone more senior and I had a very different written response from him. He said that with the benefit of two more years experience he was now satisfied that the CT coronary angiogram I originally had was correctly interpreted at the time and that there was no need for any further testing.

He changed my medication. He said that the benefits of aspirin to someone my age (68) tended to be outweighed by the risks, and that I could stop taking it. He took me off the statin to see if some other symptoms I was experiencing were side effects. He said that it took "many months" for the effects of the statin to "wear off" and that there would little extra risk of a heart attack during that time. (It doesn't look like they were side effects) . He also put me on diltiazem, instead of amlodopine, which he has had some good results with. I started taking it about 10 days ago so I await the results of that. I think the idea is to increase my dose if I am tolerating it - fingers crossed!

Personally, I don't find my condition too difficult. Sometimes when walking uphill I have to take it easy but the pain disappears within a couple of minutes. I just get on with life with a few restrictions - like I probably won't go up Cadair Idris again! Maybe at the moment I just have a mild case but I feel lucky that I don't suffer as badly as Milkfairy does.

I must say that although I didn't actually get a second opinion in person, or any further tests, the letter I had from the second cardio was incredibly thorough, and I would encourage anyone doubting their diagnosis or treatment to go down this route.

[fergusthegreat]

Hi,

Sorry to disagree but I don't think that non obstructive coronary heart disease is the same as MVA.

Non obstructive coronary heart disease is actually atherosclerosis plaque in the coronary arteries where the degree of narrowing is not deemed sufficient to cause ischemia or angina.

If the narrowing progresses and causes ischemia or angina the diagnosis changes to obstructive coronary heart disease.

Hence the diagnosis being made after an angiogram and statins being prescribed as this is the standard of care for non obstructive CAD.

[Milkfairy Heart Star in reply to fergusthegreat]

Perhaps this article will help clarify your understanding.

"Non obstructive coronary artery disease ..This umbrella term encompasses a broad range of cardiac pathophysiological abnormalities, including endothelial dysfunction, microvascular remodelling (structural), microvascular and epicardial spasm (functional), vasomotor abnormalities "

heart.bmj.com/content/105/2...

See also

stanfordhealthcare.org/medi...

You quoted from an article published in 2016, on a study of patients from 2009 to 2012.

The knowledge has moved on.

[fergusthegreat in reply to Milkfairy]

Thanks for the update, very informative 👍

[SJM2022 in reply to Milkfairy]

Thanks again. I found this article really informative and especially figure 2 which gives the flowchart on diagnosis. When I was reading it, I remembered something that happened during the procedure which I had forgotten about. The doctor advised me that he was going to do a pressure test. This was an additional procedure than just the basic angiogram, but is done during the angiogram. I recall that it made me feel very ill for the short time that the medication was put into my system - but it disappeared as soon as they stopped.

I noticed that the article mentioned this type of pressure test and this makes me think that they do have a particular diagnosis in mind which is more detailed than "NOCAD"?

[Milkfairy Heart Star in reply to SJM2022]

I am glad you found the information helpful.

I suggest you ask your Cardiologist to explain your angiogram results with you and ask for a more definitive diagnosis.

Then hopefully you can have your medication tailored to meet your specific needs.

[SJM2022 in reply to Milkfairy]

Hello. Many thanks for your previous reply - I know its been 4 months, but I just wanted to come back to you having taken your advice and contacted my cardiologist and eventually getting a reply. He said that the angiogram did show a 40% blockage in one artery but despite sounding bad, there was no reduced flow through the artery and said that if he did a similar test on the whole population, many people would have the same.

He therefore said he was 100% sure that this would not be causing my symptoms, however as there was some blockage he diagnosed NOCAD.

I then asked what would be causing symptoms and if it could be microvascular disease and he said it was unclear but even if it was MVD this would be "prognostically insignificant".

He confirmed that stopping beta blockers would be appropriate but suggested continuing with Lisinopril and aspirin and statins - all of which seem to be related to stopping the identified blockage getting worse.

This still leaves me a bit concerned about the cause of the chest discomfort (periodic and varies between resting and exercise), palpitations and nigh time awareness of heart beats.

Having said all that, it looks like the treatment I'm on may well be what is prescribed for MVD anyway so maybe I just need to accept it?

I just wondered what you thought of all this?

[Milkfairy Heart Star]

Thank you for your update. It is unfortunate that the knowledge of microvascular dysfunction and vasospastic angina is still limited amongst Cardiologists.

It took me a while to get my diagnosis.

Your Cardiologist perhaps isn't up to speed in the latest research about microvascular dysfunction and vasospastic angina.

Angina non obstructive coronary arteries ANOCA is not as your Cardiologist says.

"prognostically insignificant".

I suggest you ask your Cardiologist to read this article, which states that ANOCA is associated with greater risks of heart attacks, strokes and heart failure .

This consensus document was produced by a joint BHF and National Institute of Healthcare Research NIHR working party of expert Cardiologists.

internationalheartspasmsall...

Perhaps ask to be referred to a Cardiologist who has an understanding of ANOCA so you can access the appropriatetreatment for you.

Also perhaps get in contact with the team at St Thomas's Hospital who are carrying out the research into diagnosing ANOCA conditions.

The contact details of the researchers are at the end of thus article.

isrctn.com/ISRCTN94728379

Where in the UK are you based?

[SJM2022 in reply to Milkfairy]

Many thanks for your reply. I'm in Edinburgh, Scotland.

[Milkfairy Heart Star in reply to SJM2022]

I'll send you a message.The forum guidelines don't allow us to name individual doctors on the forum.

[SJM2022 in reply to Milkfairy]

ok