A sharp twinge, a sense of heaviness — we’ve all felt chest pain from time to time. Sometimes it’s indigestion or a panic attack. But other times, it’s more serious.

Microvascular angina is an especially worrisome source of cardiac chest pain, and it’s often misdiagnosed because it doesn’t show up as a blockage in the larger heart arteries during testing. This fact can cause doctors to miss the underlying cause.

“It’s concerning because the problem can be missed. It doesn’t show up on a traditional angiogram, which can lead to delayed diagnosis if physicians dismiss the chest pain as nothing,” says Erin Michos, M.D., associate director of preventive cardiology at the Ciccarone Center for the Prevention of Heart Disease. 

This chest pain in one of the heart’s arteries is more common in women than in men, says Michos.

What Is Microvascular Angina?

Angina is any chest pain that occurs when your heart muscle doesn’t get enough blood to meet its work demand, a condition called ischemia. 

The most common source of angina is obstructive coronary disease, which happens when one of the heart’s arteries is blocked. People with this type of angina might feel chest pain during exercise or exertion if not enough blood is supplied to the working heart muscle. 

But according to the American Heart Association, up to 50 percent of women with angina symptoms don’t have a blocked artery. In fact, they may not even have chest pain, though they may have other symptoms. 

“They may feel severely short of breath. They might feel extreme fatigue, which rest doesn’t make better. They may have pain with exertion in their back, jaw or arm with no chest pain. They might have nausea and indigestion,” says Michos.

These women should be evaluated for microvascular angina. Microvascular angina can occur when the heart’s tiniest arteries are not able to supply enough oxygen-rich blood due to spasm or cellular dysfunction. 

It can be difficult to diagnose microvascular angina because an angiogram — a specialized X-ray of the heart — won’t show obstruction or blockages in these tiny arteries, and symptoms like nausea and indigestion mimic other illnesses. Often, your doctor will perform a stress test to monitor the heart’s function during exercise to make a diagnosis. 

When the diagnosis is uncertain after a typical stress test, there are advanced tests that can be performed to evaluate for microvascular disease. This includes a special type of stress test using cardiac MRI or a technique performed at the time of an angiogram to test for dysfunction in the heart’s arteries when a usual blockage isn’t found. 

Treating Microvascular Angina

Because microvascular angina affects tiny arteries, surgical treatments that can be used on larger arteries are not an option. However, medications can reduce symptoms and improve heart health. Medications prescribed for microvascular angina include: 

• Nitroglycerin, which dilates and relaxes arteries to prevent spasms
• Beta blockers, which slow heart rate
• Statins, which can slow the progression of fatty plaque in the arteries
• Calcium channel blockers, which help relax blood vessels

Preventing Microvascular Angina

Women with microvascular angina have increased rates of stroke, heart attack and heart failure. While treatment can help reduce the risk of these complications, “the best intervention is prevention,” says Michos. 

It’s important to know your risk. “Traditional risk factors, like smoking and diabetes, that lead to blockages in the larger arteries are also risk factors for microvascular angina,” adds Michos. High blood pressure, high cholesterol and high body mass index also increase risk.

Lifestyle choices, like a healthy diet and moderate exercise, can address many of these risk factors and lower your chances of getting microvascular angina. It’s also important not to be shy about bringing up chest pain or other symptoms with your doctor.

“Women with chest pain often dismiss it. They think heart disease is a man’s disease, or that it’s indigestion or stress. The biggest thing is to create awareness that angina can happen without obstructive disease and that it’s risky,” Michos says.