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.”
“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?
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).