Is coronary microvascular disease serious? Is the Pope Catholic?

~ Carolyn Thomas

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? Had the metal stent now implanted in that LAD artery contributed to MVD?  See also: Coronary stents: interventions that come with a cost

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:

Coronary Microvascular Disease: a “trash basket diagnosis”?

My love-hate relationship with my little black box”

Misdiagnosed: women’s coronary microvascular and spasm pain

No blockages: Living with non-obstructive heart disease

Visit my Heart Sisters Patient-Friendly, Jargon-Free Glossary of cardiology terms if you need a translator!

Watch this fascinating video (26:46) from Second Opinion featuring cardiologists and patients talking about coronary microvascular disease.

♥ More videos! Watch the conference speakers (11 presentations, about 20-25 minutes each) attending the 2019 INOCA “Meeting of the Minds” meeting on non-obstructive coronary artery disease in London England in this series of videos.

♥

NOTE FROM CAROLYN:   I wrote much more about coronary microvascular disease in my book, “A Woman’s Guide to Living with Heart Disease”. You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 20% off the list price).

Published by Carolyn Thomas

26 thoughts on “Is coronary microvascular disease serious? Is the Pope Catholic?”

  1. Hello. I just turned 61 and have been having so many cardiac issues. I was diagnosed for two years with asthma (which I do NOT have), switched doctors and was diagnosed with a 95% blockage of the LAD, and stent placed 12-31-2020.

    Then continued chest pain for two years. Doctor would not listen to me so I changed doctors again earlier this year. She found a 60% and 90% blockage in the RCA. Now still have pain and shortness of breath. Was out in 1 nitro patch, then 3, then 4 and now 6. Failed cardiac rehab twice, and was told to stop.

    She highly suspects coronary microvascular disease and is going to do an angiogram to test for it. The 6 patches of nitro have helped, but I’m constantly lightheaded with low blood pressure. I also have heart muscle damage to two large muscles. This is not a journey I want to be on, but have no choice.

    My advice to women especially is to listen to your gut and don’t waiver. I’ve saved my life essentially by listening and changing doctors. I also was misdiagnosed with irritable bowel syndrome for 43 years with no relief. After searching for years, I was finally diagnosed with Mast Cell Activation Syndrome.

    Listen to your body and gut. Take care all.

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    1. Hello Linda – what a long and distressing road you’ve been on, especially with misdiagnoses years apart before being appropriately diagnosed. I’m sorry about your Mast Cell Activation Syndrome because it can affect so many areas of the body (skin, nervous system, heart, gastrointestinal tract).

      I think you’re right – you DID save your own life! Listening and changing doctors was hard when you’re feeling so sick, but you did it. Thank you Linda for reminding all of us to LISTEN TO YOUR BODY & GUT!

      Good luck to you. . . ♥

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    1. Hi Juniper – I do encourage all women to consider participating in cardiac research (even non heart-patients – sometimes researchers need a cohort of non-patients as comparison!) I have not personally been involved in the WISE studies at Cedars Sinai in Los Angeles – or at Mayo – but I do know a number of women who have survived a Spontaneous Coronary Artery Dissection who are involved with the Mayo SCAD studies. Check out the CARDIAC RESEARCH page here where I try to post cardiac studies as I hear of them that are recruiting women (including the one you’ve mentioned, plus one more WISE study I’ve posted).

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  4. Hi
    In July I had all the symptoms of heart attack, started with a pain in my chest, arms going heavy, being sick, then collapsing and losing all control over my bodily functions. I came round and an ambulance was on its way thanks to my family, but was slurring. I recovered by the time the ambulance arrived and got taken to hospital. Everything was checked and it showed raised troponin levels so was told I had a heart attack. When an angiogram was done, it showed no blockages just slight thickening on my LAD (Left Anterior Descending artery).

    Time has passed and I haven’t recovered as I thought I would. I have a lot of chest pain, very breathless and get very tired. I have been back a few times with chest pain and they said I had Dresslers syndrome, similar to pericarditis.

    I have just been to see my consultant and he said the stress MRI showed I haven’t had a heart attack and no blockages so he cant understand what happened, He can’t understand why troponin levels where raised and said it’s complicated but to stay on my medication apart from my beta blockers that might help with my breathlessness.

    I know my body isn’t right. I feel very tired often and breathless sometimes doing nothing, and there is not many days go by that I do not have pains in my chest back or arms,

    I think MVD my be what my problem is but don’t know what to do. It has helped reading Heart Sisters and this article to make me feel like I am right.

    Thank you

    Tracy

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    1. Hello Tracy – what a distressing story yours is! I’m not a physician so cannot comment specifically on your case, but I can tell you generally that raised troponins (cardiac enzymes in the blood) generally point to heart muscle injury due to heart attack. Dressler’s Syndrome is inflammation of the sac surrounding the heart, typically treated with pain relievers, anti-inflammatories or immunosuppressants like corticosteroids.

      I’m wondering what specific treatments the doctors who diagnosed each of these potential culprits offered to you? Something is causing your symptoms – right now you can’t be sure if they are heart-related or not, but good luck in being persistent until you are appropriately diagnosed.

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  5. I am a fire fighter. I had an incident when on a fire, where my heart rate was 234, I had put myself on the monitor because I was experiencing shoulder blade and leftside jaw pain along with shortness of breath. I was eventually taken to a hospital about an hour later and my heart rate was still 150’s and the pain let up but I felt like a burning in my chest. My troponin levels were very elevated and they took me to the cardiac floor and scheduled a heart cath for that next day.

    It was explained that I had narrowing in my small vessels of my heart that were too small to stent. I was told it was microvascular disease, Syndrome X. About a few weeks after work comp got involved, the doctor retracted his diagnoses and blamed my thyroid medication. I went for second and fourth opinions and they were unable to get my heart to that rate again.

    I was told by one doctor that MVD is just a term used when they can’t explain why the symptoms are there. I have tachycardia and pains and shortness of breath still and prior to that incident. I have had my thyroid med adjusted, but nothing has changed.

    I’m usually OK every day, it’s just when I am working in excessive heat and stressful situations or with high elevations like going to Colorado, I notice it and feel like I’m going to have a heart attack. No one can seem to acknowledge the MVD, when I read about it it all makes sense and describes my issues. I’m not a diabetic, and my weight was good until this incident in 2016 then my symptoms are more prevalent.

    Without diagnoses I can’t get help. I’m frustrated and confused. I spent thousands at Mayo Clinic having test with a cardiologist, they did not do another cath only other testing that showed nothing. Can you help? Anyone? I just turned 50 and not in menopause yet. I’ve been a firefighter going on 29yrs.
    Thank you.
    Theresa

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    1. Hello Theresa – I’m sorry that you are stuck in this medical mystery (symptoms but no concrete diagnosis yet). I’m not a physician so can’t comment specifically on your situation, but I can tell you generally that “very elevated” troponins (cardiac enzymes in the blood) are typically considered a marker for heart muscle damage that almost always happens due to a heart attack, so I’m not sure why your doctor decided it was not heart-related, but due to thyroid meds (and once your meds were adjusted, why did the symptoms continue?) I can also say that the doctor who told you MVD is “just a term” used when docs can’t figure out your symptoms was misinformed.

      But something is causing your distressing symptoms – and right now you just don’t know for sure what that is. You can find out more about what kind of diagnostic testing is most effective in MVD in this blog post. I have a lot of respect for Mayo cardiologists, so it may be worth considering that there might be other reasons for your puzzling symptoms. My general advice in scenarios like yours would be this: start a Symptom Journal (date, time of day, what you were doing/eating/feeling in the couple hours leading up to the start of symptoms). This journal over time can often indicate a pattern that may not normally be apparent during day-to-day recall. Best of luck to you…

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    2. Theresa, Have you gotten any help in Colorado yet? I am 57 and experiencing the same symptoms as you. I was diagnosed with MVD in 2015. It started for me at the age of 53 1/2 and I was not in menopause yet either. I went through menopause at the age of 54 so I believe it started due to a hormonal imbalance which has affected the small vessels of my heart. Never had any heart issue before this.

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  6. 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!

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    1. 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…

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      1. 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.

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          1. 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.

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            1. 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

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              1. 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.

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    1. 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…

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  9. 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?

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    1. 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.

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  10. 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

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    1. 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…

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