Why Can You Have Angina With Normal Coronary Arteries? For the Same Reason You Can Have Heart Failure With Preserved Ejection Fraction

Just in the past few months I have had three patients with crippling chest pain brought on by exercise who were dismissed as having noncardiac chest pain. All three are now essentially symptom-free on isosorbide and metoprolol – common antianginals. I may not know exactly how this treatment works, but I am passionate about providing for my patients the common medications we know work. Even a simple country doctor can do that.

Once upon a time there was only one common kind of angina and only one kind of heart failure. Now we know there are two kinds of each. For some reason doctors are all excited about the new epidemic of heart failure with preserved ejection fraction, but skeptical and uninterested in angina with normal coronaries. Both of these more recently discovered diseases turned the old definitions upside down. Doctors of my generation (and younger) have had to unlearn what they taught us in medical school. Many are still bucking.

Angina pectoris is a syndrome, a group of clinical signs and symptoms with several possible causes. When I went to school we talked of blocked coronary arteries or a rare form of angina occurring during sleep and caused by spasm, Prinzmetal‘s angina. We now know that many people, perhaps half of all angina patients, have normal coronaries as far as we can see them on catheterization but poorly functioning smaller blood vessels rather than pure spasm. This type is triggered by exertion, just like angina caused by major blockages.

Heart failure is also a syndrome. For the longest time it was believed that the problem was that the heart didn’t push the blood out well enough with each beat. Only relatively recently did it become obvious that about half of all heart failure patients have poor relaxation of the heart. We have been measuring what percentage of the blood is pumped out with each heart beat. That number should be greater than 55%. But if there is less than the normal amount of blood in the heart and you pump out only half of that, you don’t get enough pumping done for things to work.

Neither angina nor heart failure are strictly disorders of a mechanical system of plumbing. These days the term neuroendocrine pops up everywhere in the literature. Our arteries, big and small, and our heart muscles are not static but constantly changing and adapting. And our understanding of how this all works is still in the early stages.

Maybe we should trust our clinical assessment more often and not look blindly at the results of imperfect tests like Lexiscans, crude angiographies and blurry echocardiographies: If it walks like a duck and talks like a duck, maybe it really is a duck?

1 Response to “Why Can You Have Angina With Normal Coronary Arteries? For the Same Reason You Can Have Heart Failure With Preserved Ejection Fraction”


  1. 1 Christy Lane May 2, 2022 at 10:48 am

    Brilliant! This explains so much and confirms there is just so much more we don’t know yet. Thank you for sharing this.


Leave a Reply to Christy Lane Cancel reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s




Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

BOOKS BY HANS DUVEFELT, MD

Tweets

Top 25 Doctor Blogs Award

Doctor Blogs

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Mailbox

contact @ acountrydoctorwrites.com
Bookmark and Share
© A Country Doctor Writes, LLC 2008-2022 Unauthorized use and/or duplication of this material without express and written permission is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given.


%d bloggers like this: