It’s not unusual for many women who experience chest pain with unremarkable test results to hear a dismissive refrain: Your heart is fine; perhaps it’s anxiety or stress. But these symptoms may actually stem from a largely underdiagnosed yet potentially disabling condition — coronary microvascular dysfunction or disease (CMD).

Recognizing this critical gap in cardiac care, Baptist Health Heart & Vascular Care physicians have implemented protocols and strategies to more accurately diagnose and treat patients with CMD, reducing the risk of serious complications. 

CMD occurs when the tiny blood vessels in the heart are damaged, causing spasms and reduced blood flow to the heart muscle that standard imaging can’t detect. Both men and women can suffer from coronary microvascular dysfunction, but women are much more likely than men to have CMD.

Doctors aren’t sure why the discrepancy exists, but there is some belief that hormones play a role, particularly because CMD is more common in menopausal and post-menopausal women, when estrogen levels have fallen.

“Patients present with classic angina symptoms, often with exercise, yet when we take them to the cath lab, there is no evidence of obstructive coronary artery disease,” says interventional cardiologist Carlos Alfonso, M.D., director of the chronic total obstruction and complex percutaneous coronary intervention program with Baptist Health Heart & Vascular Care.

Symptoms of CMD

Angina, or chest pain, is the most common symptom of CMD. It often occurs during daily activities and exercise and typically worsens over time, with episodes becoming more common and lasting longer, leading to repeated emergency room visits. Other symptoms include:

• Shortness of breath
• Fatigue
• Sleep problems

Far from being a benign condition, CMD carries genuine cardiovascular risks. “Patients with CMD are at high risk of a major adverse cardiac event, including heart attack, heart failure and stroke,” Dr. Alfonso says. In fact, 30 to 40 percent of patients who have a heart attack do not have blockages in the major heart arteries.

Evaluation for CMD

During a patient evaluation, Dr. Alfonso and his team, who treat patients with CMD at Baptist Health West Kendall Baptist Hospital, use sophisticated testing that looks at the heart’s smallest blood vessels. To diagnose a patient, the protocol includes invasive functional measurement of coronary blood flow. After that, patients undergo endothelial function testing and coronary vasospasm provocation testing with either acetycholine to assess the function of the blood vessels’ endothelial lining. 

“We want to measure the coronary vascular flow, and with these medications we try to stimulate vasospasm. It’s a relatively simple procedure and doesn’t require much more testing than an invasive angiogram,” Dr. Alfonso says. “The benefit is a firm diagnosis. We partner with the patient’s cardiologist to provide guidance for treatment.”

Treatment for CMD

Treatment for CMD may include pain relief and the control of risk factors and symptoms. This may require the use of:

• Statins
• Blood pressure medications
• Antiplatelet medications like aspirin
• ACE inhibitors, beta blockers or calcium channel blockers
• Nitroglycerin
• Smoking cessation

When it comes to CMD, there is a need for greater awareness among the medical community so that patients receive proper diagnosis and treatment, Dr. Alfonso says. “Not all microvascular disease is of the same flavor,” he explains. “This is an area we are still studying, and as we continue to gain a better understanding of this condition, we are able to bring our patients the most updated, evidence-based and cutting-edge treatment.”

To refer a patient for CMD evaluation, call 786-204-4200