Small vessel disease

Small vessel disease is a condition in which the walls of the small arteries in the heart aren't working properly. This reduces the flow of oxygen-rich blood to the heart, causing chest pain (angina), shortness of breath, and other signs and symptoms of heart disease.

Small vessel disease may also be called:

• Coronary microvascular disease
• Microvascular endothelial dysfunction

Small vessel disease is treatable but may be difficult to detect. The condition is typically diagnosed after a health care provider finds little or no narrowing in the main arteries of the heart despite the presence of symptoms that suggest heart disease.

Small vessel disease is more common in women and in people who have diabetes or high blood pressure.

Small vessel disease signs and symptoms include:

• Chest pain, squeezing or discomfort (angina), which may get worse with activity or emotional stress
• Discomfort in the left arm, jaw, neck, back or abdomen along with chest pain
• Shortness of breath
• Tiredness and lack of energy

If you've been treated for coronary artery disease with angioplasty and stents and your signs and symptoms haven't gone away, you might also have small vessel disease.

Seek emergency medical care if you're having chest pain and other signs and symptoms such as shortness of breath, sweating, nausea, dizziness, or pain that spreads beyond your chest to one or both of your arms or to your neck.

It might be hard to tell if some symptoms are due to small vessel disease, especially if you don't have chest pain. See your health care provider to determine the cause of your symptoms.

If you have new or unexplained chest pain or think you're having a heart attack, call 911 or emergency medical assistance immediately.

In coronary small vessel disease, the small arteries don't relax (dilate) as usual. As a result, the heart doesn't get enough oxygen-rich blood.

Experts think that the causes of small vessel disease are the same as the causes for diseases affecting the larger vessels of the heart, such as high blood pressure, high cholesterol, obesity and diabetes.

Small vessel disease is more common in women than in men. Risk factors for small vessel disease include:

• Body mass index (BMI) of 30 or higher (obesity)
• Diabetes
• Family history of the disease, especially in women
• High blood pressure
• Inactive lifestyle
• Increasing age: older than 45 in men and older than 55 in women
• Insulin resistance
• Polycystic ovary syndrome
• Tobacco use
• Unhealthy cholesterol levels
• Unhealthy diet

Small vessel disease can make it harder for the heart to pump blood to the rest of the body. A possible complication of small vessel disease is a heart attack.

Things you can do that might reduce your risk of small vessel disease include:

• Don't smoke or use other tobacco products. If you smoke or use tobacco, stop. Talk to your health care provider if you have trouble quitting.
• Eat a heart-healthy diet. Choose a diet rich in whole grains, lean meat, low-fat dairy, and fruits and vegetables. Limit salt, sugar, alcohol, saturated fat and trans fats.
• Exercise regularly. Regular exercise helps improve heart muscle function and keeps blood flowing through the arteries. Aim for at least 150 minutes a week of moderate activity such as walking.
• Maintain a healthy weight. Excess weight strains the heart and can contribute to high cholesterol, high blood pressure and diabetes.
• Manage cholesterol. Ask your health care provider how often you should have your cholesterol numbers checked. If your bad cholesterol (low-density lipoprotein cholesterol) levels are high, your health care provider may prescribe changes to your diet and medications to help lower your cholesterol levels and protect your cardiovascular health.
• Control blood pressure. Ask your health care provider how frequently you should have your blood pressure measured. He or she might recommend more-frequent checks if you have high blood pressure or a history of heart disease.
• Control blood sugar. Work with your health care provider to establish blood sugar goals that are right for you.
• Manage stress. Find ways to help reduce emotional stress. Getting more exercise, practicing mindfulness, listening to music and connecting with others in support groups are some ways to reduce stress.

To diagnose small vessel disease, your health care provider will usually do a physical exam and ask questions about your medical history and family history of heart disease. He or she will likely listen to your heart with a stethoscope.

The tests used to diagnose small vessel disease are similar to those used to diagnosis other types of heart disease and include:

• Stress test with imaging. A stress test measures how the heart and blood vessels respond to activity. You may be asked to walk on a treadmill or pedal a stationary bike while connected to a heart monitor. Or you may be given an IV drug to stimulate the heart in a way similar to exercise. Blood flow to the heart muscle is measured with ultrasound images (echocardiogram) or with nuclear imaging scans.

• Coronary angiogram. This test helps determine if the main arteries to the heart are blocked. A long, thin flexible tube (catheter) is inserted into a blood vessel, usually in the groin or wrist, and guided to the heart. Dye flows through the catheter to arteries in the heart. The dye makes the arteries easier to see on X-ray images and video.

  Additional tests may be done during an angiogram to measure blood flow through the heart.

• CT coronary angiogram. This other type of angiogram uses a powerful X-ray machine to produce a series of images of the heart and its blood vessels. You'll lie on a long table that slides through a short, tunnel-like machine (CT scanner). Dye injected through an IV in the arm or hand makes blood vessels easier to see on the CT images.
• Positron emission tomography (PET). This test uses a radioactive tracer and medication to measure blood flow to the heart muscle. After the tracer is injected, you usually lie in a doughnut-shaped machine to have images taken of the heart.

The goals of treatment for small vessel disease are to control the narrowing of the small blood vessels that can lead to a heart attack and to relieve pain.

Medications for small vessel disease may include:

• Nitroglycerin (Nitrostat, Nitro-Dur). Nitroglycerin tablets, sprays and patches can ease chest pain by relaxing the coronary arteries and improving blood flow.
• Beta blockers. These drugs slow the heart rate and decrease blood pressure.
• Calcium channel blockers. These drugs relax the muscles around the coronary arteries and cause the blood vessels to open, increasing blood flow to the heart. Calcium channel blockers also help control high blood pressure and coronary artery spasms.
• Statins. These medications help lower bad cholesterol, which contributes to the narrowing of the arteries. Statins also help relax the blood vessels of the heart and treat blood vessel damage.
• ACE inhibitors and ARBs. Drugs called angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) help open blood vessels and lower blood pressure. This makes it easier for the heart to pump blood.
• Ranolazine (Ranexa). This medication eases chest pain by altering sodium and calcium levels.
• Aspirin. Aspirin can limit inflammation and prevent blood clots.
• Metformin. This drug is typically prescribed to lower blood sugar in people with diabetes, but it can improve blood vessel health even in those who don't have diabetes.

If you're diagnosed with small vessel disease, you'll need regular checkups with your health care provider.

Heart-healthy lifestyle changes can help prevent and manage small vessel disease. Lifestyle changes may include:

• Losing weight if you're not at a healthy weight
• Getting regular physical activity
• Eating a healthy diet that's low in salt and rich in fruit, vegetables, lean protein and whole grains
• Quitting smoking or tobacco use

Sometimes, the dietary supplement L-arginine may benefit people with small vessel disease who haven't been helped by other medications. L-arginine is an amino acid that helps relax blood vessels.

Talk to your health care provider before taking any supplements to make sure that they won't interact with other medications that you take.

If you've had chest pains or other symptoms of heart disease, your primary care provider will likely refer you to a doctor trained in heart diseases (cardiologist).

Here's some information to help you get ready for your appointment.

What you can do

When you make the appointment, ask if there's anything you need to do in advance, such as avoiding food or drinks before a specific test.

Before your appointment, make a list of:

• Your symptoms, including any that seem unrelated to the reason for your appointment
• Important personal information, including major stresses and recent life changes
• Any personal and family medical history of heart disease, high blood pressure, diabetes or high cholesterol
• All medications, vitamins or other supplements you take, including the doses
• Questions to ask your care provider

For small vessel disease, basic questions to ask your health care provider include:

• What's causing my symptoms?
• Are there other possible causes for my symptoms?
• What tests do I need?
• What treatments are available and which do you recommend for me?
• What are the alternatives to the primary approach you're suggesting?
• I have other health conditions. How can I best manage them together?
• Should I see a specialist?
• Are there brochures or other printed material I can have? What websites do you recommend?

Don't hesitate to ask other questions.

What to expect from your doctor

Your health care provider is likely to ask you questions, such as:

• When did your symptoms begin?
• Do you always have symptoms or do they occur occasionally?
• How severe are your symptoms?
• What, if anything, makes your symptoms worse?
• Do your symptoms get worse when you're active?
• What, if anything, makes your symptoms better?