Prevalence of ANOCA and discordance between anginal symptoms and coronary functional abnormalities in patients with mental health disorders: Insights from the Japanese CMD Registry

Background Angina with non-obstructive coronary arteries (ANOCA) remains a significant diagnostic and therapeutic challenge. While persistent symptoms often lead to psychological distress, comorbid mental health disorders may conversely amplify symptom perception. Although anxiety and depression are linked to coronary functional abnormalities, it remains difficult to distinguish psychogenic from cardiogenic chest pain. The prevalence of ANOCA and its specific contribution to the symptom burden in patients with mental health disorders remain poorly characterised. Purpose To evaluate (1) the prevalence of ANOCA and (2) the relationship between anginal symptom burden and invasive coronary functional abnormalities in patients with mental health disorders. Methods Of 1,285 consecutive patients with chest pain enrolled in the Japanese Association of Coronary Microvascular Dysfunction (J-CMD) Registry, 679 were analysed after excluding those with obstructive coronary artery disease (n=214) or incomplete data (n=392). Mental health disorders were defined by a documented diagnosis of anxiety/depression or the use of psychotropic medications. Anginal symptoms were quantified using the Seattle Angina Questionnaire (SAQ) summary score. ANOCA was diagnosed via invasive coronary functional testing, including coronary spasm provocation and assessment of coronary microvascular dysfunction (CMD). Prevalence of ANOCA and associations between SAQ scores and coronary functional findings were compared by mental health disorder status. Results Of the 679 patients, 52 (7.7%) had mental health disorders. This cohort was more likely to be female, younger, and current smokers. The prevalence of ANOCA was high and comparable between those with and without mental health disorders (65.4% vs. 69.1%; P=0.641), as was the prevalence of coronary spasm (46.2% vs. 49.3%; P=0.773). However, SAQ scores were significantly lower (indicating greater symptom burden) in patients with mental health disorders (58.7±22.4 vs. 66.7±17.5; P=0.002). Multivariable logistic regression identified mental health disorders as an independent predictor of lower SAQ scores (OR 2.71; 95% CI 1.41–5.09; P=0.003) after adjusting for CMD and coronary spasm. Importantly, lower SAQ scores correlated with the presence of ANOCA in patients without mental health disorders (P=0.012), but this association was absent in those with mental health disorders (P=0.532; P-interaction=0.129). Conclusion Patients with mental health disorders exhibit a high prevalence of ANOCA, similar to those without such comorbidities. Notably, mental health disorders are independently associated with a greater symptom burden that is dissociated from objective coronary functional abnormalities. These findings underscore the necessity of a biopsychosocial approach, integrating physiological and psychological assessments to optimise the management of patients with ANOCA.