Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients.

Podcast Summary

Introduction

Dr. Warrick Bishop, a cardiologist, author, and CEO of the Healthy Heart Network, hosts this episode with guest Dr. Fiona Fu, an interventional cardiologist based in Sydney with expertise in women's cardiovascular health. The episode explores angina and ischemia caused by non-obstructive coronary artery disease—conditions where patients experience chest pain and reduced blood flow to the heart despite having no significant blockages in the major coronary arteries, particularly affecting women.

Key Takeaways

• ANOCA (angina with non-obstructive coronary arteries) and ENOCA (ischemia with non-obstructive coronary arteries) are conditions where narrowing less than 50% in arteries causes chest pain and reduced blood oxygen, traditionally overlooked in favor of diagnosing major artery blockages.

• The problem occurs at the microvascular (small blood vessel) level, analogous to having clear highways but obstructed small neighborhood streets—the small vessels cannot be visualized on standard angiograms but can be assessed through functional angiography.

• Coronary microvascular dysfunction and coronary artery spasm are two primary mechanisms of non-obstructive coronary disease, with spasm able to occur in both large and small vessels and potentially causing dramatic vessel narrowing (up to 90%).

• These conditions predominantly affect women far more frequently than men, though males can also develop them, particularly when there is a family history of coronary artery spasm.

• Risk factors for non-obstructive coronary disease include high blood pressure, high cholesterol, obesity, and psychological stress—overlapping with general cardiovascular disease risk factors.

• Coronary microvascular dysfunction is closely linked to heart failure with preserved ejection fraction (a stiff heart), suggesting shared underlying pathophysiology in these conditions.

• The causes of microvascular dysfunction are multifactorial, including microvascular obstruction, inflammation, and problems with coronary flow reserve, with research still ongoing.

• Many patients with these conditions are incorrectly dismissed as having no heart problems after normal angiograms, leading to significant frustration, emotional distress, and impaired quality of life.

• Functional coronary angiograms can now definitively diagnose these conditions through testing vessel function and inducing spasm with acetylcholine, enabling targeted treatment approaches.

• While outcomes are better than atherosclerotic coronary artery disease, patients with non-obstructive coronary disease still have increased risk of heart attacks and poor cardiac outcomes, making diagnosis and management of risk factors essential.

• Greater clinical awareness and prioritization of these conditions as a differential diagnosis is needed, particularly given the significant improvement in quality of life and outcomes when properly recognized and treated.