Angina With Normal Coronary Arteries

In the vast majority of patients with angina, their symptoms are caused by typical coronary artery disease (CAD), in which an atherosclerotic plaque is partially obstructing a coronary artery. In these cases, a stress test is likely to show evidence of a discrete blockage in one or more of the coronary arteries, and coronary angiography usually will readily identify the number and location of the obstruction or obstructions.

Angina is so closely associated with typical CAD in the minds of most patients and many healthcare providers, that patients with apparent angina who have a “normal” angiogram are often told, in no uncertain terms, that their chest discomfort is due to something other than angina. And, it is true that a number of non-cardiac conditions can produce chest discomfort.

Sometimes, however, true angina can occur in the absence of typical CAD. Sometimes patients who are experiencing angina with apparently “normal” coronary arteries actually do have a cardiac problem that needs to be diagnosed and treated.

Several cardiac and medical conditions can cause angina even without atherosclerotic plaques that are producing discrete blockages in the coronary arteries. Some of these conditions actually do involve the coronary arteries, while others do not.

Coronary Angiography, France
BSIP / UIG / Getty Images

Conditions Involving the Coronary Arteries

There are at least four disorders of the coronary arteries that can cause cardiac ischemia and angina without producing blockages that can be seen on angiography. All of these conditions are more commonly seen in women, though they sometimes occur in men.

Furthermore, all four of these conditions have features that ought to alert the healthcare provider (and the patient) that the patient's symptoms are indeed cardiac in nature despite the ostensibly "normal" angiograms and should lead to further evaluation and ultimately to appropriate therapy.

  • Vasospastic (Prinzmetal's) angina: Severe spasm of the coronary arteries.
  • Coronary microvascular dysfunction: A condition involving the small coronary arteries that cannot be visualized on a coronary artery angiogram.
  • Female-pattern CAD: A poorly recognized form of atherosclerotic CAD that is seen mainly in women.
  • Coronary artery erosions: An ulcer-like lesion in coronary arteries that is next to impossible to see on angiography, but which can lead to acute coronary syndrome.
  • Spontaneous coronary artery dissection (SCAD): SCAD can cause angina in the absence of a typical blockage and occurs much more frequently in women than men.

Especially if you are a woman, and you are having symptoms strongly suggestive of angina, but you have been given a "clean bill of heart health" after a "normal" angiogram, you need to make sure your healthcare provider has carefully considered each of these four conditions before pronouncing you healthy.

Conditions Not Directly Involving the Coronary Arteries

Sometimes angina can occur when portions of the heart muscle are not getting enough oxygen even though the coronary arteries themselves are completely normal. Conditions that can produce angina without coronary artery disease include:

In general, these conditions occur in patients who are quite sick, and the angina is usually just one of an array of symptoms. So healthcare providers taking care of these patients are not likely to be led into a false sense of complacency by the absence of classic CAD.

4 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Kempf J, Buysman E, Brixner D. Health resource utilization and direct costs associated with angina for patients with coronary artery disease in a US managed care setting. Am Health Drug Benefits. 2011;4(6):353-61

  2. Lanza GA. Diagnostic approach to patients with stable angina and no obstructive coronary arteries. Eur Cardiol. 2019;14(2):97-102. doi:10.15420/ecr.2019.22.2

  3. Waheed N, Elias-Smale S, Malas W, et al. Sex differences in non-obstructive coronary artery disease. Cardiovasc Res. 2020;116(4):829-840. doi:10.1093/cvr/cvaa001

  4. Parsyan A, Pilote L. Cardiac syndrome X: mystery continues. Can J Cardiol. 2012;28(2 Suppl):S3-S6. doi:10.1016/j.cjca.2011.09.017

Additional Reading
  • Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126:3097.

  • Mosca, L, Manson, JE, Sutherland, SE, et al. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association. Writing Group. Circulation. 1997;96:2468.

By Richard N. Fogoros, MD
Richard N. Fogoros, MD, is a retired professor of medicine and board-certified in internal medicine, clinical cardiology, and clinical electrophysiology.