Angina with Normal Coronaries

Evidences have been shown that about 30% patient’s who admitted due to chest pain ,  Coronary angiograms show normal coronaries and 60% of post PTCA patients’ show TMT positive for inducible angina .

Normal or nonobstructive coronary disease at angiography is not uncommon and occurs in 10% of women presenting with ST segment elevation myocardial infarction compared with 6% in men.

Randomized placebo-controlled studies have demonstrated that tricyclic antidepressants, beta-blockers, ACE inhibitors, L-arginine, statins and exercise may relieve symptoms, vascular dysfunction, or both, however, long-term studies evaluating cardiac event rates need to be performed.

Features of chest pain may suggest:

- Non-cardiac chest pain

- Atypical angina including vasospastic angina

- Cardiac syndrome X

Normal coronary angiograms do not exclude the presence of myocardial ischemia in women. Coronary disease and chest pain, which may occur despite normal routine angiograms, include variant angina and syndrome X. Differentiation between these 2 entities may not be possible without further specialized provocation tests.

Important to differentiate non-cardiac chest pain from other 2 conditions:

- if angiographic appearance are suggestive of non-obstructing lesions and stress imaging techniques identify an extensive area of ischemia then :

- Intravascular USG of assessment of coronary flow reserve or fractional flow reserve may be considered to exclude missed obstructive lesions.

- Intra coronary ACETYLCHOLINE or ERGONOVIE may be administered during coronary arteriography .