One of the situations I come across in cardiac practice is a woman with chest discomfort, breathlessness, or unusual fatigue who undergoes an angiogram and is told that her coronary arteries are clear. The immediate reaction is often, “Then there is nothing wrong with my heart." A clear angiogram is certainly reassuring. It tells us that the major coronary arteries have no significant blockage. At the same time, the heart has a much larger circulation, and some problems can involve the smaller blood vessels.

This is particularly relevant in women, who may experience symptoms related to the smaller vessels or the way the coronary circulation responds when the heart needs more blood.

When The Major Arteries Are Clear

I often explain the coronary circulation with a simple example.

Think of the major coronary arteries as highways carrying blood towards the heart. An angiogram gives us a detailed picture of these larger vessels and helps identify significant narrowing or blockages.

But every highway eventually connects to smaller roads. These smaller vessels also play an important role in delivering blood to the heart muscle.

The tiny blood vessels supplying the heart may sometimes struggle to widen adequately when the heart requires more oxygen. In some patients, the coronary vessels may also go into spasm, temporarily reducing blood flow.

This is one of the situations associated with coronary microvascular dysfunction and may fall under a broader condition called ischaemia with non-obstructive coronary arteries, or INOCA. Studies have found INOCA particularly frequently among women.

So, when symptoms continue despite a clear angiogram, the smaller vessels and the functioning of the coronary circulation may deserve further evaluation.

Why Does This Matter Particularly For Women?

Women may experience cardiac symptoms differently from the classic picture many of us have grown up with.

A woman may experience breathlessness while walking or climbing stairs, chest pressure, unusual fatigue, discomfort in the back, shoulder, jaw or upper abdomen, nausea, dizziness or a decline in exercise capacity.

These symptoms can easily be attributed to acidity, stress, poor sleep, menopause or a demanding routine.

I encourage women to pay attention to a change from their usual health. A symptom that keeps returning or begins affecting everyday activities deserves a clinical assessment, even when an earlier angiogram showed clear major coronary arteries.

A Clear Angiogram Does Not Mean Cardiovascular Risk Has Disappeared

An angiogram tells us a great deal about the major coronary arteries. Cardiovascular risk, however, depends on several other factors as well.

In India, risk factors such as obesity, high blood pressure and elevated blood sugar are common among women. A nationwide analysis of NFHS-5 data involving 7.2 lakh women aged 15-49 found central obesity in 78.2%, overweight or obesity in 23.9%, raised blood pressure in 11.8% and raised blood sugar in 8.6%.

High blood pressure, diabetes, high cholesterol, obesity, physical inactivity, smoking and a family history of heart disease all influence long-term cardiovascular health.

A woman's cardiovascular risk also changes through different stages of life. The transition around and after menopause deserves particular attention because several risk factors may become more prominent during this period.

What If Symptoms Continue After A Clear Angiogram?

A clear angiogram provides useful reassurance about the major coronary arteries. Persistent symptoms deserve a fresh clinical conversation.

Depending on the symptoms and individual risk profile, a cardiologist may evaluate other possible causes, including coronary microvascular dysfunction or coronary artery spasm. In selected patients, specialised tests can assess how the smaller coronary vessels are functioning and how blood flow responds to increased demand.

The goal is simple: understand the reason behind the symptoms and identify the appropriate treatment.

Five Things Women Should Remember

1. Pay Attention To Recurring Symptoms.

Chest discomfort, breathlessness, or unexplained fatigue that keeps returning deserves a conversation with your doctor, even after a clear angiogram.

2. Understand What An Angiogram Tells You

An angiogram provides valuable information about the major coronary arteries. The smaller vessels and the way the coronary circulation functions may require additional assessment.

3. Watch For Changes In Your Daily Routine

If activities that were previously comfortable suddenly leave you breathless or unusually tired, pay attention to that change. Your exercise capacity often provides an important clue about your cardiovascular health.

4. Know Your Cardiovascular Numbers

Keep track of your blood pressure, blood sugar and cholesterol. This becomes especially important if you have diabetes, hypertension, obesity or a family history of premature heart disease.

5. Look Beyond The Obvious Explanation

Acidity, stress, poor sleep and menopause can all produce symptoms that overlap with cardiac conditions. Persistent or new symptoms deserve proper medical assessment so that the underlying cause can be identified.

Other heart conditions, including valvular heart disease, adult congenital heart disease and arrhythmias, can also cause symptoms such as breathlessness, fatigue, chest discomfort or reduced exercise capacity. These conditions require separate evaluation and may not be explained by an angiogram of the coronary arteries.

Beyond The Angiogram

One of the important lessons in cardiovascular care is that the heart involves a complex network of blood vessels, each playing a role in delivering oxygen to the heart muscle.

For some women, the issue may lie in the smaller vessels or in the way blood flows through the coronary circulation. Recognising this possibility helps doctors investigate persistent symptoms more thoroughly and helps patients understand why symptoms deserve attention even after a reassuring angiogram.

A clear angiogram is good news. When symptoms continue, the next useful question is, 'What else could be affecting the heart?'

Finding that answer is often the first step towards the right treatment.

(Dr Ajeet Bana, Chairman, Cardiac Sciences, EHCC Hospital, Jaipur)



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