Cardiology · United Arab Emirates
A 61-year-old man continued to experience exertional chest tightness after invasive coronary angiography reported no obstructive disease, and sought clarity on what the result did and did not exclude.
The patient had hypertension, type 2 diabetes and a family history of premature coronary disease. A CT coronary angiogram reported mild non-calcified plaque with less than 50% stenosis; invasive angiography confirmed non-obstructive epicardial disease. Symptoms persisted on a beta blocker and statin.
“What clinical entities are usually considered when angina persists despite non-obstructive coronary arteries, and what further assessment is typically discussed?”
Dates are expressed as intervals rather than calendar dates, and identifying details have been altered, so that the sequence of care can be followed without identifying the patient.
Month 0
Exertional chest tightness on climbing two flights of stairs, relieved by rest. Background of hypertension, type 2 diabetes and a father with myocardial infarction at 54.
Month 0 + 3 weeks
Mild non-calcified plaque in the proximal left anterior descending artery, stenosis reported as under 50%. Calcium score 96.
Month 2
Beta blocker and high-intensity statin commenced; sublingual glyceryl trinitrate supplied.
Month 5
Performed for ongoing symptoms. Reported non-obstructive epicardial coronary arteries; no intervention. No coronary function testing performed at the same sitting.
Month 6
Patient continued to report exertional tightness with a reproducible exercise threshold and occasional early-morning episodes at rest.
Month 7
Two hospitals' records consolidated into one timeline; symptom diary aligned with investigation dates and medication changes.
Month 7 + 3 days
Reviewed by a consultant cardiologist with a dedicated chest-pain clinic practice, with no affiliation to either treating hospital.
Month 8
Further functional assessment arranged by the treating team; lipid management reviewed at the same appointment.
Every item supplied by the patient was indexed before review. Nothing was assessed in isolation from the rest of the record.
Merged into a single chronological record to expose gaps and duplications.
Plaque burden and stenosis grading reviewed against symptom severity.
Assessed for what was and was not tested — specifically the absence of coronary function testing.
Reviewed for ischaemic change and chronotropic response on beta blockade.
Left ventricular function and regional wall motion assessed.
Compared against secondary-prevention targets usually applied in diabetes with established plaque.
Used to characterise exertional versus rest-predominant episodes.
Every report ends with a prepared question list. The questions are written to be asked of the patient's own clinician — they are prompts for discussion, not recommendations.
Extracts from the signed specialist report, reproduced in the same section order used in every MedReview 365 report.
The patient discussed microvascular assessment and lipid intensification with his cardiologist, who arranged further functional testing. Any change to medication was made by his own doctor.
This case study is anonymised, published with patient consent and altered where necessary to prevent identification. It describes how one written second opinion was prepared and discussed. It is not a treatment recommendation, not a diagnosis, and not an indication of any expected result in another patient. Always discuss your care with your own treating clinician, and seek emergency care for urgent or deteriorating symptoms.