Is coronary microvascular disease serious? Is the Pope Catholic?

22 Oct

by Carolyn Thomas    @HeartSisters

It’s time for physicians to stop telling patients that a diagnosis of coronary microvascular disease (MVD) is no big deal. Or alternatively, to accept that the diagnosis is real in the first place. As one of my blog readers learned to her horror, this awareness is not yet universal. When she asked her own physician, for example, if her debilitating cardiac symptoms might be due to coronary microvascular disease, he replied: “I don’t believe in microvascular disease!” – as if they’d been discussing the damned Tooth Fairy.

But here’s how Dr. Stacey Rosen, a cardiologist and spokeswoman for the American Heart Association’s Go Red For Women campaign, answered a question about microvascular disease in the New York Times recently:

Q: “I have been diagnosed with microvascular heart disease, which I was told mostly affects women and is not considered serious in and of itself. How long can it exist before it turns into serious heart disease?”

A:  “MVD can lead to heart attacks, heart failure and death. It’s serious.”

She added:

“This is NOT a benign diagnosis, and it absolutely can be treated and needs to be treated.

“Decades ago, when we didn’t understand this, we told women they didn’t have heart disease and they should take Maalox or anti-anxiety medication, when in fact this was a form of ischemic heart disease that was poorly understood.”

Dr. Rosen explained that the type of coronary artery disease that generally causes heart attack typically means a build-up of plaque inside one or more of the large arteries supplying oxygenated blood to the heart muscle. But coronary microvascular disease (also called small vessel disease) affects the tiniest branches of these large vessels. Abnormalities in the endothelium (inner lining) of these smaller vessels can also cause spasms, resulting in diminished blood flow to the heart and resulting severe chest pain.

I like the simple and straightforward way these smaller blood vessels are described in Second Opinion:

Blood flows to the heart muscle first through three large coronary arteries (ranging from 1.0 – 4.0 millimeters in size), and then through branches of thousands of smaller arteries called arterioles (ranging from just 0.1 to 0.5 millimeters in size). Healthy arteries are hollow tubes and that inner lining, the endothelium, is smooth and elastic, allowing blood to flow freely. When you exercise, a healthy artery can stretch to let more blood flow to your body’s tissues. The transition from large artery to smaller arteriole is a gradual one, marked by a progressive thinning of the blood vessel wall and a decrease in the size of the inner passageway. The job of those larger arteries is to distribute blood. The job of the arterioles is both blood distribution and resistance (pressure and flow regulation). Think of the arterioles as being like “taps” for circulation, turning the flow up or down to match the needs of your body.

In my own case, I experienced two types of heart disease for the price of one: the textbook widow maker heart attack (caused by a blocked left anterior descending coronary artery – one of the heart’s large blood vessels) followed within months by a second diagnosis of MVD (caused by endothelial dysfunction of those small arterioles). I wonder now which came first? Had I been living with small vessel disease for years before my heart attack/

As Dr. Rosen explains, standard cardiac tests like angiograms, routinely used to detect most coronary artery blockages, cannot detect abnormalities in these smaller vessels, so more specialized diagnostic tests may be required for an accurate diagnosis.

Treatment for coronary microvascular disease typically involves medications that help the coronary arteries to relax, keep cholesterol and blood pressure in check, prevent blood clots, and manage chest pain. See also: Coronary Microvascular Disease: a “trash basket diagnosis”?

In my own case, I also wear a small portable TENS unit every day, clipped to my belt, its tiny wires snaking under my clothes up to the sticky electrodes taped over my chest – another treatment option for coronary microvascular disease symptoms. My pain specialist at our hospital’s Regional Pain Clinic, who spent a year in Sweden on a fellowship research grant studying coronary microvascular disease, also recommends this innovative, affordable, effective, non-drug, non-invasive treatment for the chest pain of refractory angina (that’s chest pain that doesn’t respond to standard cardiac medications). It’s apparently more commonly recommended to patients with MVD in the UK and other countries compared to North America.

But just as important as clinical treatments, Dr. Rosen warns, physicians must also strongly recommend lifestyle changes. Quit smoking, for example, because tobacco damages the endothelium.  Regular exercise, on the other hand, has a beneficial effect on the endothelium. Dr. Rosen reminds us: “It is also important to mitigate other risk factors for heart disease and to keep medical conditions like Type 2 diabetes in check.”

PLEASE NOTE: No matter what treatment options are made available (or not) to any patient living with this heart condition, it’s important to comprehend the profound difference between my blog reader’s experience with her non-believer doctor, and my own.

Imagine having two specialists (both my cardiologist and my pain specialist) who were not only extremely knowledgeable about coronary microvascular disease, but one of them had spent an entire year of post-graduate training studying only this condition! Imagine how straightforward my path to an appropriate diagnosis was, compared to the virtual impossibility of that reader’s condition being correctly diagnosed at all.

And the worst part: she is not alone.

I regularly hear from women who have been finally diagnosed, sometimes after years of suffering and diagnostic failures. I know that I won the heart patients’ lottery when I met my two well-informed professionals.

If you too have been diagnosed with coronary microvascular disease, Dr. Stacey Rosen suggests that you must see your doctor regularly, be scrupulous about taking your medications and making important lifestyle changes, and be prepared to call for immediate help if you even think you may be having a heart attack. Shortness of breath, crushing fatigue or pain in the jaw, left arm, back or neck may be warning signs of microvascular dysfunction or an imminent heart attack. Read more about heart attack symptoms as well as early warning signs.

Q: Have you or somebody you care about been diagnosed with Coronary Microvascular Disease?

See also:

I wrote more about coronary microvascular disease in my new book, “A Woman’s Guide to Living with Heart Disease”  (Johns Hopkins University, November 2017. 

16 Responses to “Is coronary microvascular disease serious? Is the Pope Catholic?”

  1. Amy April 16, 2018 at 3:21 pm #

    I am 47 and on paper, the picture of health. I exercise and watch what I eat – although everything in moderation. My BMI is 20, my blood work is perfect, and I have passed my EKG, Echo, and calcium screening tests. As a matter of fact, my calcium score was a 0 which is perfect.

    However, I have had chest pain/spasms/angina for ten weeks. I have diagnosed myself with MVD as I am still waiting to get into a cardiologist.

    I really don’t want to be put on any medications so thank you for sharing about your TENS unit. I will ask about that when I finally get an appointment. I guess the biggest issue I have is that I always feel that a “heart attack” could occur in the next minute or two because my heart is “busy.”

    However, thanks for this article; it is so helpful!

    Liked by 1 person

    • Carolyn Thomas April 16, 2018 at 5:15 pm #

      Hello Amy – I’m glad you found this article (and links to others here, too!) I’m not a physician so can’t comment specifically on your distressing symptoms

      You may indeed have MVD, although right now the truth is that you don’t know for sure if your symptoms are heart-related or not. We know that up to 85% of all people admitted to hospital with chest pain (meaning their cardiac diagnostic tests did show up something suspicious in the ER) have pain that turns out not to be cardiac in nature. More here. So much of medicine, I’ve learned, is just trying to figure out what the problem is NOT. Here are other examples of conditions that mimic cardiac pain.

      Yes, it’s very, very common to feel that a heart attack is imminent when you have any type of chest pain. Truly scary! It took me a long time to stop feeling freaked out at every twinge. For that reason, although you don’t want to take meds, you might welcome a trial of nitroglycerin if MVD is ultimately diagnosed. I would never leave home without it: it’s a fast-acting vasodilator and one of our oldest and safest cardiac meds.

      But back to your symptoms: I’m glad you’re going to see a cardiologist; while you’re waiting, try keeping a Symptom Journal to show to your cardio (date, time of day, what you were doing/eating/feeling in the hours leading up to the symptoms, etc.) Sometimes a clear pattern starts emerging that could help both of you solve the mystery. And remember you can always get a second opinion from another cardiologist.

      Best of luck to you…

      Like

      • Amy April 17, 2018 at 12:06 pm #

        Carolyn,
        Thank you for your response and the extra expertise. I am so thankful for your blog and you are so selfless to pour out to all of us women. I will start a Symptom Journal and report back after I get some definitive answers.

        Liked by 1 person

        • Carolyn Thomas April 17, 2018 at 4:38 pm #

          Thanks for your kind words, Amy. I look forward to hearing how your appointment goes…

          Like

          • Amy April 19, 2018 at 5:02 pm #

            Well, I had my appointment today and was steamrollled. The doctor had another EKG done and it came back normal. He then came in and told me that he could say with 100% certainty that I did not have a problem with my heart.

            He suggested a muscle issue. I do Pilates and light weightlifting so it made me wonder if he was right. I am 50/50 right now. However, I will say this. He did not seem to really know MVD – he lumped it under the category of Printzmetal’s Angina, which is different, right? He also told me it wasn’t my heart because it happened mainly when I was at rest and “that is not the heart.” He also said that I was a pre-menopausal non-smoking woman with excellent tests results and should just take a “Motrin.”

            Okay, I have to admit that I am hoping he is right and it is just my muscles deep down that are tweaking/twerking, but I have a new empathy for any woman trying to get a real diagnosis for MVD. This is a top cardiologist in a top cardiac hospital. I left embarrassed but hopeful that I do not have heart disease. I will wait a month without exercising and see what is going then.

            Liked by 1 person

            • Amy April 24, 2018 at 1:42 pm #

              Hi Carolyn,
              I’m sorry; I’m back with more questions. I have narrowed the muscle issue down to possibly “costochondritis.” I haven’t been exercising but I still have the “spasms/angina/pressure.” I have been thinking about what the cardiologist said to me. He said that the “angina” is never present all day long. What is your experience with that?

              I can “feel it” all day long, but it may not be super active but once a day–where I really worry about it. Usually I just have pokes, stretches, blips here and there or maybe some rib/back pain. Then, occasionally (like right now) it really builds and feels quite active with a lot of pressure. That’s when I worry. Could that be costo? I can’t really say it is “my heart” because I do have not palpitations, but I know I have something alive in my upper chest cavity and it doesn’t like me! 🙂

              Also, I am at a loss at to where to go now. Do I go back to my primary care physician and tell her I think I have this (costo) or this (mvd) and by the way, your cardiologist doesn’t really even know what mvd is? Maybe I need a second opinion? And then would that cardiologist be any better? What tests would get a diagnosis for either? It doesn’t seem like either are really definable. Ugh.

              Sorry for the barrage of questions, but I’m frustrated with the health care system and right now, you are by far the most qualified person to consult.
              Thank you for any comment. 🙂
              Amy

              Liked by 1 person

              • Carolyn Thomas April 24, 2018 at 3:11 pm #

                Hello again Amy – I’m not a physician (I have to keep saying that just to reinforce the reality that I’m not actually a “qualified person to consult!”)

                But it is entirely possible that costochondritis could make sense as a diagnosis. Please read this blog post about costo, and make sure you watch the two videos there by Steve August, a physiotherapist in New Zealand (where costo is widely treated successfully by physiotherapists, not physicians with antibiotics). One hint that it might be musculo-skeletal is if the pain can be reproduced by pushing on the chest…

                I think it’s worth a try to consider this possible diagnostic option.

                Like

                • Amy April 25, 2018 at 5:47 am #

                  Thank you! I will start researching. 🙂

                  Like

                  • Sandra Sizer April 29, 2018 at 7:33 am #

                    Amy, PLEASE research another cardiologist for a second [or third, if necessary] opinion.

                    Like

  2. Ankit Karma October 28, 2017 at 4:59 am #

    You provide me a great answer to my questions. Thanks for sharing this article.

    Like

  3. Shar October 22, 2017 at 12:57 pm #

    I found that a very low carb diet reduced many of my symptoms. The inflammatory response from carbs is something to look at.

    Liked by 1 person

    • Carolyn Thomas October 22, 2017 at 3:25 pm #

      Hi Shar – I too have heard this. I’ve also read, however, that some studies show low-carb diets were associated with more damaging heart attacks than control groups, and may impair recovery immediately following a heart attack. For severe cases of refractory angina, it may be worth a (short-term) try to personally assess symptom management. Always best for MVD patients to check with their docs first…

      Like

  4. Connie Crogal October 22, 2017 at 10:10 am #

    Great information. Thank you.

    Can coronary microvascular disease be reversed if caught early? Can testing for microvascular disease be included as part of a regular checkup for women to diagnose it early and prevent further damage? Treating to reverse this serious heart disease early would be less expensive with no suffering and save countless lives in the process the way I see it.

    Is a simple, non-invasive test available for that purpose for doctors at the General Practitioner level to use routinely for (early prevention) to help women who are underrepresented and under treated?

    Is research being done to find an inexpensive tool for doctors to use for this elusive disease and what could be used and done in the interim and are doctors getting the message that checking for microvascular heart disease should be part of their protocol and of an urgent matter for their women patients?

    Liked by 1 person

    • Carolyn Thomas October 22, 2017 at 3:04 pm #

      You’re asking a lot of great questions! I’m not a physician, but I can guess that the answers, in order, are no, no, no, very little, and I don’t think so. Watch the video to hear experts like Dr. Noel Bairey Merz share interesting background info on this condition. Prevention is generally better than waiting for debilitating symptoms to reveal themselves, but in some cases it seems that’s not yet possible. Best bet: risk factors for MVD are similar to those of all coronary artery diseases In my opinion, we should ALL be living every day as if we are at very high risk for heart disease. There’s simply no downside in doing so!

      You can read more about the most reliable current diagnostic tests for MVD here (to my knowledge, there is no valid non-invasive test yet) and GPs would be highly unlikely to order invasive diagnostic procedures (that are not without risk). It’s not as straightforward as diagnosing high blood pressure, unfortunately.

      Like

  5. Lu Ann May October 22, 2017 at 4:56 am #

    I look forward to your post every Sunday. I have now been diagnosed with coronary microvascular disease. I am taking nitro morning and night which is helping with the angina. I still have pain all day, everyday. I took another trip by ambulance to the ER. They said it was just angina. I don’t think so, but this is probably the best it’s going to get. Thank you for being there.
    Sincerely,
    Lu

    Liked by 2 people

    • Carolyn Thomas October 22, 2017 at 2:52 pm #

      Thanks for your kind words, Lu. I hate it when people call it “just angina”! What you are experiencing IS angina – angina caused by the condition called coronary microvascular disease! I’m not a physician but I can tell you that some MVD patients, depending on the severity and duration of angina pain, benefit from wearing a nitro patch if chest pain is persistent or worsening. Ask your doctor if this is an option for you. Best of luck…

      Liked by 1 person

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