Evaluation of Patients With Chest Pain and Normal Coronary Angiograms

ver 1 million coronary angiograms are performed in North America annually, and a significant number are interpreted as normal.In the Coronary Artery Surgery Study Registry of the 1970s, normal angiograms were found in 19% of patients, 1 and the prevalence may not have changed in the current era of more sophisticated noninvasive testing.A recent study found that 19% of patients had no arteriographic evidence of disease. 2 For women selected for angiography, a normal result is found 3 times more frequently than for men. 1,2Further elucidation of the diagnosis in a patient population of this size is of obvious importance.However, correctly investigating and managing the treatment for such patients can be challenging.On the one hand, a potentially serious, yet manageable condition must not be overlooked.On the other hand, excessive anxiety over a problem that may not exist or may not be serious must not be created.Therefore, the finding of a normal angiogram in a patient with chronic chest pain in whom coronary disease was suspected prior to the procedure must lead to a thorough investigation (Figure 1).The pathophysiologic features, investigation, and treatment of chest pain in these patients are the subject of this review.