In this episode of PodMD, General and Interventional Cardiologist, Dr Kunal Nagar will be discussing the topic of unpacking non-obstructive coronary artery disease.
- Transcript
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*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Kunal Nagar.
Dr Kunal Nagar is an Australian-trained General and Interventional Cardiologist at Advara HeartCare. He has a keen interest in chest pain assessment, arrhythmias, heart failure and preventive cardiology. Dr Nagar has extensive experience across major Australian hospitals, now based on the Sunshine Coast. He is a dedicated educator and mentor, committed to patient-centred care, with special interests in coronary intervention, intravascular imaging, and coronary functional testing.
Today, we’ll be unpacking the topic of Non-Obstructive Coronary Artery Disease
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of Dr Kunal Nagar, not PodMD.
If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.Kunal, thanks for talking with us on PodMD today.
Kunal:Thanks for having me.
The topic of today’s discussion is Non-Obstructive Coronary Artery Disease. Kunal, Can you describe for our listeners what Non-Obstructive Coronary Artery Disease is?
Kunal:Non obstructive coronary artery disease or NOCAD, is a condition where a patient experiences classic symptoms of heart disease like chest pain, shortness of breath, or even signs of ischemia on stress testing; but when we perform an angiogram, there are no significant blockages in the large coronary arteries or the major epicardial vessels. Typically, we define this as less than 50% narrowing. Now for a long time, this was thought to be a benign finding, and unfortunately, many patients, especially women, were told that their symptoms weren’t cardiac in origin, but we know now that that’s not the case. NOCAD or non obstructive coronary disease encompasses a spectrum of pathologies like coronary microvascular dysfunction and vasospastic angina. This involved the smaller vessels or abnormal constriction of the arteries, which can still impair blood flow to the heart muscles. What’s really important to emphasise is that it just isn’t a diagnostic curiosity, NOCAD is associated with real morbidity, reduced quality of life, and even adverse cardiac outcomes. That’s why there’s a shift in focus towards coronary functional testing. It allows us to diagnose these conditions more accurately, and tailor therapy to improve outcomes for this often overlooked group of patients.
Question 1
How would a patient with Non-Obstructive Coronary Artery Disease typically present?Kunal: Patients with non obstructive coronary artery disease typically presents just like those with classic obstructive coronary disease. They might come in with chest pain, often described as pressure, tightness or discomfort. It may be brought on by physical exertion or emotional stress, and sometimes it can even occur at rest. Shortness of breath is another symptom, and in some cases patients report fatigue, palpitation or reduced exercise tolerance. What’s particularly important is that these symptoms can be persistent. Even those standard tests like angiography might not show any major blockages. Now, women in particular are more likely to have NOCAD and may present with slightly different or more diffused symptoms like nausea, lightheadedness or pain that isn’t strictly in the chest, which can sometimes lead to under diagnosis. So in short, these patients often just look like any other cardiac patient, and that’s why it’s so important not to dismiss these symptoms just because the coronary arteries appears normal on initial testing.
Question 2
What are the risk factors of this condition?Kunal: The major risk factor for non obstructive disease are similar to those for traditional coronary artery disease, though the underlying mechanisms are a little bit different. The key risk factors include the traditional cardiovascular risk factors such as hypertension, high cholesterol, diabetes and obesity; which can contribute to endothelial dysfunction and microvascular abnormalities. Lifestyle factors like smoking, physical inactivity and chronic stress, which exacerbate cardiovascular risk and may increase the likelihood of developing NOCAD. Gender plays a role, with women being a little bit higher risk for NOCAD and often experience more severe atypical symptoms. Now understanding this risk factors is crucial for early detection and management of NOCAD, particularly since it can present without significant coronary blockages on angiography but still carries substantial cardiovascular risk.
Question 3
What are the treatment options?Kunal: Now the treatment option for NOCAD focuses on symptom management and reducing cardiovascular risk, as there are no significant blockages on angiography. So, the first one to go would be lifestyle modification. We would encourage a heart healthy diet, regular physical activity, smoking cessation and stress management strategies. The next one would be the pharmacological options we have; the first four most would be antiplatelet therapy like with aspirin. This balancing first out the bleeding risk as that would be quite important. this would help to reduce the thrombotic risk. The second one here would be statins for further cholesterol management and stabilisation. The other one here would be the renin angiotensin system blockers like ACE or ARB for blood pressure control and symptom relief. Then we would have beta blockers which would help us reduce the heart rate and oxygen demand of the heart. There’s a special medicine for refractory angina. And last but not least, ongoing monitoring is the key, because we would need to have regular follow up to adjust the patients medication as the symptom control is better or not. Now tailoring individual treatment to patients need is crucial considering multiple comorbidities and symptoms severity. Early intervention combined with comprehensive lifestyle changes is the key to improving long term outcomes for this disease.
Question 4
Have there been any developments in treatment in the last years or are there any in trials or development now?Kunal: In the recent times, there have been multiple development and treatment and understanding of NOCAD and one of the recent trials, the Warrior trials, has been quite promising. They tried to explore intensive medical therapy in women with ischemia with non obstructive coronary disease. Unfortunately, this study was a neutral study which found no significant reduction of major cardiovascular event over five years; but this highlights the complexity of managing NOCAD. We now these days have multiple innovative diagnostic tools, advanced imaging techniques which are improving, which would help us to diagnose NOCAD, help quantify blood flow a little bit more accurately in reducing further need for invasive procedures. Ongoing research and trials are further refining of our approach to diagnose and managing NOCAD which will show the targeted and effective treatment strategies are level in future.
Question 5
Are there any warning signs a GP or their patient can look out for?Kunal: For GP than patients, recognising the warning signs of NOCAD is essential for early intervention. Key symptoms to watch for would include chest pain or discomfort, often triggered by physical activity or stress, but it can also incur stress, shortness of breath or fatigue that is unexplained or worsens with exertion, atypical chest pain, which may not be localised, or may radiate to other areas, especially in women, palpitation, or irregular heartbeats, which may indicate microvascular dysfunction. Although NOCAD doesn’t choose any significant blockages on angiography, these symptoms along with risk factors like hypertension, diabetes and a sedentary lifestyle should prompt further evaluation and consideration of NOCAD as a potential diagnosis.
Question 6
When should a GP refer?Kunal: I would say GP should refer a patient for further evaluation if there is persistent or unexplained chest pain, particularly if it’s atypical or occurs at risk, despite no significant findings on initial investigations. Symptoms of heart failure or significant fatigue, especially with risk factors like hypertension, diabetes or a history of smoking. Unresolved shortness of breath that doesn’t correlate with other conditions or when conventional treatments don’t provide relief. Atypical presentations, particularly in women, when symptoms may be more diffused like described earlier, nausea, lightheadedness, or discomfort not limited to the chest. Referral is a key for advanced diagnostic workup, like coronary functional testing, which can uncover microvascular dysfunction or other subtle abnormalities not visible on standard imaging.
Question 7
What role does the GP play in the treatment of the condition?Kunal: I believe GP plays very a key role in managing NOCAD by early detection, recognising symptoms like chest pain or shortness of breath, even when angiography shows no significant blockage. Managing risk factors by controlling high blood pressure, diabetes and cholesterol to reduce the cardiovascular risk. Encouraging lifestyle support and facilitating smoking cesation and stress management strategy. Medication management, prescribing and monitoring treatments like statin and beta blockers while coordinating with cardiologists if needed, and then ongoing care providing continuous follow up and patient education to ensure effective symptom control and adherence. GP are essential in early intervention, risk reduction in long term management for patients with NOCAD.
Question 8
Kunal, thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast Non-Obstructive Coronary Artery Disease.Kunal: NOCAD is a significant condition. While there are no major blockages on angiography, NOCAD still carries a substantial risk for adverse cardiovascular events, including heart attack and heart failure. Early detection and management are crucial, recognising symptoms like unexplained chest pain or shortness of breath and managing risk factors like hypertension, diabetes and cholesterol are key in reducing long term risk. GP plays central role; they’re quite essential in early diagnosis, risk management and providing ongoing support while coordinating care with cardiologists for advanced treatments when needed.
Thanks again for your time and the insight’s you’ve provided.
Kunal: Thank you.
