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A further explanation for chest pain without visible coronary artery disease

Tom Newman, Paul Morris and Julian Gunn
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DOI: https://doi.org/10.7861/clinmed.Let.21.2.3
Clin Med March 2021
Tom Newman
Academic foundation year-2 trainee, University of Sheffield, Sheffield, UK
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Paul Morris
Senior clinical lecturer and Wellcome Trust research fellow, University of Sheffield, Sheffield, UK and consultant cardiologist, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Julian Gunn
Professor of interventional cardiology, University of Sheffield, Sheffield, UK and honorary consultant cardiologist, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Editor – we read with interest the review and recommendations by Rogers et al on how to identify and manage functional cardiac symptoms.1 The messages resonate with our experiences both on the acute take and in the clinic. The authors refer to ‘syndrome x’ as an alternative name for non-cardiac chest pain (NCCP) whereby patients have chest pain without evidence of epicardial coronary artery disease. While many cases of chest pain without epicardial coronary disease are non-cardiac in nature, it is increasingly recognised that up to 50% of patients with anginal symptoms, investigated in the catheter laboratory, have symptoms caused by coronary microvascular dysfunction (CMD). This has become known as ischaemia with non-obstructed coronary arteries (INOCA).2 INOCA can be challenging to diagnose because it is not seen at angiography. It is, therefore, frequently overlooked. This is unfortunate because it is associated with increased risk of cardiac events yet responds to stratified medical therapy.2,3

Rogers et al describe how medically unexplained symptoms are associated with younger age and female sex, two factors which are also associated with CMD and INOCA.2,4 Guidelines on investigation and management of INOCA have recently been published by the European Society of Cardiology.5 We recognise the difficulty faced by clinicians in identifying functional syndromes and that they are highly prevalent. Given the prognostic implications of CMD and the fact that it is a potentially treatable condition, it is important that clinicians consider the diagnosis of INOCA before labelling symptoms as non-cardiac in origin.

  • © Royal College of Physicians 2021. All rights reserved.

References

  1. ↵
    1. Rogers J
    , Collins G, Husain M, Docherty M. Identifying and managing functional cardiac symptoms. Clin Med 2021;21:37–43.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Kunadian V
    , Chieffo A, Camici PG, et al. An EAPCI expert consensus document on ischaemia with non-obstructive coronary arteries in collaboration with European Society of Cardiology Working Group on coronary pathophysiology & microcirculation endorsed by Coronary Vasomotor Disorders International. Eur Heart J 2020;41:3504–20.
    OpenUrl
  3. ↵
    1. Ford TJ
    , Stanley B, Good R, et al. Stratified medical therapy using invasive coronary function testing in angina: the CorMicA trial. J Am Coll Cardiol 2018;72:2841–55.
    OpenUrlFREE Full Text
  4. ↵
    1. Sara JD
    , Widmer RJ, Matsuzawa Y, et al. Prevalence of coronary microvascular dysfunction among patients with chest pain and nonobstructive coronary artery disease. JACC Cardiovasc Interv 2015;8:1445–53.
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Neumann FJ
    , Sechtem U, Banning AP, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020;41:407–77.
    OpenUrlCrossRefPubMed
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A further explanation for chest pain without visible coronary artery disease
Tom Newman, Paul Morris, Julian Gunn
Clinical Medicine Mar 2021, 21 (2) e242; DOI: 10.7861/clinmed.Let.21.2.3

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A further explanation for chest pain without visible coronary artery disease
Tom Newman, Paul Morris, Julian Gunn
Clinical Medicine Mar 2021, 21 (2) e242; DOI: 10.7861/clinmed.Let.21.2.3
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