Normal Coronary Arteries: Clinical Implications and Further Classification

Abstract

The term "chest pain with normal coronary arteries" encompasses a large number of different cardiac pathophysiological abnormalities, including impairment of coronary flow reserve, endothelial dysfunction, and early atherosclerosis that, in most cases, cannot be readily differentiated one from the other. To study early coronary atherosclerosis, physicians must look beyond contrast filled arteries (so called lumenology). Angiograms cannot evaluate the vessel wall, plaque distribution and composition or other morphology. Plaques are often angiographically not visible due to their small size and compensatory enlargement (outward remodeling) of the coronary arteries. As a result, the search for an underlying atherosclerotic process remains ongoing. Available clinical studies showed that many patients with chest pain and normal angiography have early atherosclerosis as documented by intravascular ultrasound imaging, reduced coronary flow reserve and coronary endothelial dysfunction. Additional studies showed that patients presenting with normal coronary angiography have recurrent coronary events at long-term follow up. Research to determine if improved diagnosis and treatment of quantitatively low degrees of atherosclerosis lead to improved outcomes of patients with normal angiography should be undertaken.

Ischemia in women with angina and normal coronary angiograms

“…It is currently recognized that coronary endothelial dysfunction can be detected in some patients with minimally obstructive coronary artery disease and angina [7,8,[17][18][19][20]. Thus, endothelial dysfunction in microvascular angina has been explained as a generalized process that can involve both coronary and peripheral conduit arteries and is similar to that observed in patients with organic atherosclerotic disease [21].…”

Relationship Between Brachial Artery Flow-Mediated Dilation, Carotid Artery Intima-Media Thickness and Coronary Flow Reserve in Patients With Coronary Artery Disease

“…Previous studies demonstrated that vasomotor dysfunction of epicardial coronary arteries is a predictor of cardiac events in patients without angiographic evidence of CAD [22]. In addition, it was shown that many patients with chest pain and normal vessels at coronary angiography have early atherosclerosis, as documented by intravascular ultrasound, reduced CFR and coronary endothelial dysfunction [23, 24]. …”

Echocardiographic ‘brainstorm’ to detect anomalous origin of the left coronary artery from the pulmonary artery

“…Nevertheless, the analysis should always be integrated with coronary angiography and CT scan in order to access the precise location of the LCA origin and the location of its network of collaterals before choosing the appropriate intervention, as in the case reported. [14][15][16][17][18][19][20][21][22] …”