By Serena Agusto-Cox | News & Views

Cardiac rehabilitation (CR) professionals can help patients whose ischemia, chest pain, or myocardial infarction (MI) occurs without obstructive coronary artery disease. However, the absence of a blockage does not mitigate other risk considerations that should be accounted for in rehabilitation planning.

In a recent AACVPR webinar, “Nonobstructive Mischief: When Angina Isn’t Obstructive Coronary Disease,” Debbie Lin Teodorescu, MD, MEng, AM, FACC, explained that patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) and ischemia with nonobstructive coronary arteries (INOCA) experience heightened cardiovascular morbidity, recurrent symptoms, and diminished quality of life.

“I wince when I think about how many times in my earlier career I must have missed coronary dysfunction,” she admits. “The patients who had chest pain without a satisfying explanation and eventually stopped telling their doctors, or the patients with disabling heart failure with preserved ejection fraction whose symptoms were simply chalked up to deconditioning.”

When "Normal" Arteries Don't Tell the Whole Story

A coronary evaluation showing no obstructive disease can lead medical professionals to conclude that the danger has passed. “It's akin to celebrating when a CT scan shows no lung cancer, but there are signs of COPD or pneumonia,” Dr. Teodorescu warns. In many cases, these patients don’t receive a referral to cardiac rehab.

But patients with MINOCA and INOCA are still at elevated risk for short-term adverse outcomes from ischemia, like dysrhythmia, as well as mid- to long-term risks, such as worsening cardiovascular health and heart failure. “These are all risks that modern management methods can significantly reduce,” she explains.

For rehabilitation teams, the focus is on helping patients’ coronary circulation function as reliably and efficiently as the body demands during daily activities and exercise.

The Cost of Delayed Recognition

Dr. Teodorescu recently cared for a woman in her 70s whose decades of recurring symptoms illustrate the consequences of delayed recognition.

The patient experienced her first MINOCA event in her 30s, followed by intermittent episodes of MINOCA and INOCA that presented with classic chest pain. Although those events occurred over many years, an explanation for the periodic episodes remained elusive. Once an avid hiker, she gradually became sedentary as symptoms persisted.

“By the time I met her, she already had significant heart failure from her heart weakening from being starved on and off of blood for so many years,” Dr. Teodorescu shares. Despite the delay in diagnosis, pharmacologic treatment combined with cardiac rehab helped address both the heart failure and underlying coronary dysfunction. The story has a twist: during the discussion of her mother's condition, the patient's daughter realized she herself had begun to experience similar chest pain despite imaging that showed no coronary blockages. Today, both women are participating in cardiac rehab.

Cardiac Rehab's Critical Role

CR professionals already have experience relevant to caring for patients diagnosed with MINOCA and INOCA. As Dr. Teodorescu notes, the key adjustment is to expand risk stratification beyond whether or not a major blockage is present: “What is the likelihood of uncontrolled angina or complications of ischemia during cardiac rehab?” she asks. That question puts coordination with the treating cardiology team at the center of rehabilitation planning.

Dr. Teodorescu shares, “In our practice at Pulse Heart Institute, this means coordinating with the referring clinician to understand the patient's ischemic and arrhythmic risk with exertion, the symptoms that should prompt modification or termination of exercise, and the patient's individualized plan for breakthrough angina. We also try to establish before rehabilitation what therapies are effective for symptom control, and when recurrent or refractory symptoms should prompt reassessment by the treating cardiology team. Patients whose symptoms remain inadequately controlled despite medical therapy may benefit from additional treatment before or alongside rehabilitation.”

Coronary dysfunction is substantially underdiagnosed and underrecognized even in the United States. “Patients sometimes have struggled to find an explanation of why they feel poorly, can develop skepticism around medical care, and all too often decrease their activity levels dramatically to prevent angina development,” Dr. Teodorescu warns.

An Opportunity to Improve Outcomes

The need for greater awareness was one of the primary motivations behind the webinar. Inspired by the experiences of the Pulse Heart Institute’s cardiac rehabilitation team, Dr. Teodorescu wanted to help CR professionals better understand the growing population of patients who experience ischemia, angina, and MI without obstructive coronary artery disease.

“They knew a lot of this already from simply being observant about their patients,” she acknowledges. “But putting the pieces together helps clinicians understand the bigger picture, including the large number of patients affected, the shift away from a binary blocked-versus-unblocked view of coronary disease, ways to risk-stratify patients, and how to partner with cardiologists to achieve symptom control.”

Coronary dysfunction represents one of the largest unmet needs in cardiovascular medicine today, according to Dr. Teodorescu, who says the patients are common, the consequences real, and the opportunity to improve outcomes enormous.

She emphasizes three key takeaways for cardiac rehabilitation professionals:

• Ischemia and even MI can occur without obstructive coronary disease
• Cardiac rehabilitation remains one of the most powerful tools available to improve symptoms, function, and confidence
• Many of the skills CR professionals use every day translate exceptionally well to this patient population

“Ultimately, this is about helping patients who have too often been told that nothing is wrong, or that if there is something wrong, there's nothing that can be done about it,” Dr. Teodorescu says. “Cardiac rehabilitation professionals are in a unique position not only to improve exercise capacity and cardiovascular health but also to restore trust, hope, and quality of life.”