Can you have angina without ischaemia?

[Tos92]

Good evening,

I hope everyone is doing well today.

I have recently just had some results come back from a CMR with Perfusion scan that I did. After being diagnosed with an NSTEMI back in January 2022 on the back of having a myocardial bridge (MB) and vasospasm in Dubai, the recent results are negative for ischaemia, and no scarring. It also indicates an LVEF (left ventricular ejection fraction) of 67% which I’m assuming is within the normal range.

However, a myocardial perfusion scan which was conducted last year in May 2022 showed areas of reversible ischaemia, which is slightly contradictory to the results found in the CMR with perfusion. Unless this ischaemia has resolved with time.

Therefore, my question is whether it’s possible to have angina in the absence of ischaemia?

I remain symptomatic with chest pain, back pain and arm pain on a daily basis. The cardiologist is now considering vasospasm as a result of the MB, with a low burden of ischaemia.

[Hidden]

Hello a logical answer would be no - Cardiac ischemia is decreased blood flow and oxygen to the heart muscle. Angina is the symptom as a result of restricted blood flow. Whether due to obstructive or non obstructive heart issues. That’s my basis understanding though.

[Tos92]

It’s strange because my GTN spray helps with the chest pain when I have extreme bouts of pain, although used sporadically because of the MB.

I was under the assumption that the GTN spray helps relieve pain that’s ischaemic?

[Tos92]

Got it - thanks.

I mentioned the latter to my cardiologist today, with the GTN being contraindicated in MBs, to which he said he had never heard of that and has previously treated patients with MBs with a GTN spray. He wanted to add GTN in oral form to help reduce the pain that I experience daily, but I declined on this occasion based on what you have just mentioned until I know more about its effects on MBs.

[Hidden in reply to Tos92]

both my local cardiologist (very learned) and the MB testing cardiologist (my local one referred to the testing one as a National expert) said the same - no nitrates for me.

[Milkfairy Heart Star]

Tos92 Hidden

There is also the issue of a mismatch of the amount of blood the heart muscle demands and the ability of the the coronary blood vessels to supply the blood needed.

If your small blood vessels are unable to dilate or stay dilated in response to extra demands such as exercise, a person will feel chest pain due to microvascular dysfunction, so microvascular angina.

Whilst vasospastic angina is due to transient constrictions of the coronary arteries, though you can have vasospasms in the small vessels too.

ncbi.nlm.nih.gov/books/NBK4....

A mismatch of supply and demand can occur if your heart rate is too low or high. When there are arrthymias present or anaemia.

Low or very high blood pressure. The heart muscle itself is unable to pump sufficient blood due to heart failure.

All of these can lead to a lack of perfusion of blood to the heart muscle.

Angina, as Fishface has said is a symptom of the lack of blood supply to the heart muscle whatever the underlying cause.

GTN spray helps relax all smooth muscle which is found in any tubular hollow organ of the body. That's why GTN spray is used to treat oesophageal spasms too.

GTN will not be able to treat the other possible causes of a lack of blood to the heart such as anaemia, arrthymias, raised or low heart rate or blood pressure.

Using the response to GTN is not necessarily a good way to try and diagnose angina.

There is also some evidence that suggests GTN and nitrates are less affected in relieving chest pain due to microvascular dysfunction.

It would be great if you could see a Cardiologist who understands both myocardial bridges and coronary vasospasms.

Which probably means a trip to London.

[Tos92 in reply to Milkfairy]

Thanks for your input Milkfairy .

I believe there to be arrhythmias present; however, my holter monitor doesn’t seem to catch these. What it does seem to log is an excess of ectopic beats.

In terms of anaemia, my haemoglobin seems to be within normal range. My last blood test was at the end of December 2022. So I don’t believe there is any anaemia present currently.

The cardiologist I’m seeing is London based; however, has a clinic in Milton Keynes which is easier for me to get to. I have provided him with a CD which contains my angiogram and he will review this with what he has said very competent and knowledgeable cardiologists at his hospital in London that can determine the characteristics of my MB and whether this is in fact, the main cause of my symptoms as I was reluctant to use GTN tablets as a daily form of treatment for the pain.

I was under the the impression that the CMR with perfusion would rule out, or rule in microvascular angina but there was no mention of this. However, I do experience a lot of pain on rest so perhaps it is more in line with vasospasm, as diagnosed in Dubai as opposed to microvascular angina. Hoping it isn’t a case of both, vasospasm and microvascular angina, as I’m not sure how I would manage both together.

I will be emailing him the research trial study which you sent me as I mentioned to him that they are taking place in a few London hospitals to get his input on this.