Bridging the Gap with Dr. G Season 1: Autoimmunity, Cardiovascular Health & Wellness
When “Normal” Heart Tests Aren’t the End of the Story
Understanding INOCA and the Small Vessels of the Heart
“They told me my arteries were clear.”
“My stress test was normal.”
“They said it wasn't my heart.”
And yet…
The chest pressure is still there.
The shortness of breath hasn't disappeared.
You're unusually tired with activity—or perhaps you've simply noticed that you can't do what you used to do without symptoms.
For many women, this can be both reassuring "and frustrating."
After all, a normal or reassuring cardiac test is good news.
But sometimes it isn't the end of the story.
Because heart disease isn't always about a major blocked artery.
❤️ The Heart Has Large Vessels—and Very Small Ones
When most of us think about coronary artery disease, we picture cholesterol plaque narrowing one of the large arteries that supply blood to the heart.
Those blockages are extremely important.
But the heart's circulation is much more complex.
The large coronary arteries branch into progressively smaller vessels, eventually forming an intricate network called the coronary microcirculation.
These tiny vessels help regulate blood flow according to how much oxygen the heart muscle needs.
Sometimes the large coronary arteries are open…
but the smaller vessels—or the way the coronary arteries function—aren't working normally.
That's where INOCA enters the conversation.
🔎 What Is INOCA?
INOCA stands for:
Ischemia with No Obstructive Coronary Arteries
Let's translate that.
Ischemia means the heart muscle isn't receiving enough oxygen-rich blood for its needs.
No obstructive coronary arteries means there isn't a major blockage significantly obstructing blood flow through the large coronary arteries.
So yes:
You can have ischemic symptoms without having a major coronary blockage.
Two important reasons are:
🩸 Coronary Microvascular Dysfunction
The tiny vessels responsible for regulating blood flow may not dilate normally or may create too much resistance to blood flow.
⚡ Coronary Vasospasm
A coronary artery can temporarily constrict or spasm, reducing blood flow.
Some people may have features of both.
This is important because INOCA isn't one single condition—and understanding the mechanism may influence treatment.
Why Does This Matter So Much for Women?
Because women are disproportionately affected by nonobstructive patterns of coronary disease and coronary microvascular dysfunction.
Historically, cardiovascular disease was often viewed primarily through the lens of obstructive disease in the large coronary arteries.
If those arteries looked relatively clear, symptoms could sometimes be attributed to something else.
But our understanding has evolved.
No major blockage does not automatically mean no cardiovascular problem.
That's an important distinction.
And for women experiencing persistent symptoms, it can change the conversation from:
“We didn't find anything.”
to:
“What else might explain what you're experiencing?”
🌉 Think Beyond the Big Arteries
The coronary circulation contains both the large arteries we commonly think about and a vast network of much smaller vessels.
The large coronary arteries can develop plaque that narrows blood flow, and significant blockages can often be identified with appropriate cardiac imaging.
The coronary microvessels have a different job. These tiny vessels help regulate blood flow to the heart muscle based on its changing needs.
And they can function abnormally even when there isn't a major blockage in the large coronary arteries.
That's why I want you to remember this simple message:
NO MAJOR BLOCKAGE ≠ NO PROBLEM
Symptoms may still result from abnormal blood-flow regulation in the coronary microcirculation or from coronary vasospasm.
But this also doesn't mean every persistent symptom is caused by INOCA.
It means we keep asking the right questions.
Where Does Autoimmunity Fit?
This brings us back to where this series began.
Remember the endothelium—the delicate inner lining of our blood vessels?
It plays an important role in regulating vascular tone and blood flow.
Chronic inflammation, metabolic dysfunction, high blood pressure, smoking, abnormal lipids and other cardiovascular risk factors can affect vascular function.
For women living with autoimmune or chronic inflammatory disease, their inflammatory history becomes another piece of the cardiovascular puzzle.
That does not mean every woman with autoimmune disease and chest discomfort has microvascular disease.
It means we shouldn't evaluate her symptoms without considering her whole cardiovascular story.
Context matters.
🩺 “But My Stress Test Was Normal…”
A normal test is valuable information.
We should never dismiss that.
But here's something I want every patient to understand:
Every test answers a particular question.
And no single cardiovascular test can identify every possible cause of chest discomfort or ischemia.
Depending on the clinical situation, further evaluation may sometimes involve tests capable of examining blood flow to the heart muscle, such as PET or stress cardiac MRI.
In selected patients, specialized invasive testing can evaluate how the coronary arteries and microcirculation respond and help identify microvascular dysfunction or vasospasm.
That does not mean everyone with persistent chest discomfort needs advanced testing.
It means the next step should be determined by the person's:
Symptoms • Risk factors • Previous testing • Medical history • Physical findings • Overall clinical picture
Again:
Personalization matters.
🩺 Dr. G's Perspective
One of the most important questions we can ask in medicine is:
“Did the test we performed actually answer the question we're asking?”
If we're asking whether there is a major obstructive coronary blockage, one group of tests may answer that question very well.
But if we're asking whether the coronary microcirculation is functioning normally, we may need to ask a different question.
This is where listening matters.
Symptoms matter.
Risk factors matter.
Family history matters.
Metabolic health matters.
And inflammatory and autoimmune disease history can matter.
“Nothing obstructive was found” and “nothing cardiovascular is happening” are not necessarily the same statement.
At the same time, not every episode of chest discomfort is cardiac.
Good medicine means being willing to consider both possibilities.
🌿 What Does This Mean for You?
If you experience persistent or recurring:
Chest pressure, tightness or discomfort
Shortness of breath
Unusual fatigue
Reduced exercise tolerance
or other symptoms that concern you…
…and your initial cardiovascular testing has been reassuring, don't diagnose yourself with INOCA.
Instead, start with a better question:
“Could there be another explanation for my symptoms that hasn't yet been evaluated?”
And when appropriate:
“Could coronary microvascular dysfunction or vasospasm be part of the differential?”
You're not telling your healthcare professional what the diagnosis is.
You're opening the door to a more complete conversation.
Bridge Builder Challenge
This week's challenge is about your story, not another laboratory number.
If you're experiencing recurring symptoms, write down:
What does it feel like?
What brings it on?
How long does it last?
What makes it better?
Does it happen with activity, emotional stress—or at rest?
Is it becoming more frequent or intense?
Bring that information to your healthcare professional.
Because sometimes the pattern tells us something a single test cannot.
❤️ One Minute Heart Check with Dr. G
Ask yourself:
Have my symptoms changed?
Are they becoming more frequent?
Do they limit my activity?
Have I stopped doing things because I'm worried the symptoms will occur?
Those details matter.
And an important reminder:
New, severe, prolonged or rapidly worsening chest discomfort—particularly with shortness of breath, sweating, nausea, faintness or other concerning symptoms—requires urgent medical evaluation.
Don't wait for a blog post or your next routine appointment.
💬 Join the Conversation
Have you ever experienced persistent cardiovascular symptoms even though your initial testing was reassuring?
You don't need to diagnose yourself.
But you are allowed to keep asking questions.
Share this article with another woman who needs to know that cardiovascular health isn't always simply about finding—or not finding—a blocked artery.
A reassuring test is valuable.
Persistent symptoms still deserve an explanation.
🌉 Bridging the Gap with Dr. G
Connecting the dots between symptoms, science & solutions.
— Dr. G
Disclaimer: This article is intended for educational purposes only and does not provide medical diagnosis or individualized treatment. New, severe or worsening chest pain or other potentially cardiac symptoms require prompt medical evaluation.
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