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A new view of nonobstructive coronary artery disease

Images show the left and right coronary arteries, as seen during an angiogram.
Images show the left and right coronary arteries, as seen during an angiogram. (Photo: National Library of Medicine)

Images show the left and right coronary arteries, as seen during an angiogram. (Photo: National Library of Medicine)

In coronary artery disease (CAD), a waxy substance called plaque builds up inside the coronary arteries, which supply oxygen-rich blood to the heart muscle. CAD is the leading cause of death in the United States in both men and women.

Nonobstructive CAD occurs when those deposits do not obstruct the blood flow to the heart. Such deposits are found in 10 to 25 percent of patients who are given a coronary angiogram, an imaging test that uses X-rays and a special dye to see inside the arteries. Angiograms are typically done for patients who are complaining of chest pain or shortness of breath, or who have failed cardiac stress tests.

According to The New York Times, "Historically, doctors have considered the partial obstructions insignificant, and a surprisingly large percentage of patients with them are sent home without treatment." A new VA study, however, indicates that nonobstructive CAD should not be ignored, especially among patients who are showing symptoms of heart disease.

A team led by researchers from the VA Eastern Colorado Health Care System and the University of Colorado gathered data on 37,674 Veterans who underwent elective angiograms at VA between October 2007 and September 2012. Of those, 22 percent had nonobstructive CAD.

As expected, the risk of having a heart attack or dying within one year was greatest among the 55 percent of Veterans in the study with obstructive coronary disease (those with a blockage equal to or greater than 70 percent in one or more coronary arteries). But those with nonobstructive CAD in even one artery had twice the risk of suffering a heart attack of those without any trace of CAD, and the risk was more than four times greater if they had nonobstructive disease in two or three arteries. The death rate increased with the extent of nonobstructive disease.

Dr. Thomas M. Maddox, the study's lead author, told the Times that patients should not consider a diagnosis of nonobstructive CAD "good news," and that "if an angiogram shows a blockage of 30, 40, or 50 percent in one or more arteries, the patient should be on preventive therapy," such as daily baby aspirins and statins. (Journal of the American Medical Association, Nov. 5, 2014)

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