Angina Without Blocked Arteries Carries No Added Heart Attack Risk Over 15 Years: Study Shows
Denmark: Patients presenting with angina symptoms but without obstructive coronary artery disease may not face the long-term cardiovascular risks traditionally associated with the condition, a large population-based study from Denmark has shown.
The research, published in JACC: Cardiovascular Interventions, suggests that angina with no obstructive coronary arteries (ANOCA) is not linked to a higher risk of myocardial infarction over 15 years and is associated with only a modest increase in ischemic stroke risk and a slightly lower risk of death compared with the general population.
The study was led by Kevin K.W. Olesen, MD, PhD, from the Department of Cardiology at Aarhus University Hospital, Denmark, and challenges the prevailing perception that ANOCA represents a particularly high-risk cardiovascular state requiring intensive long-term surveillance. Current international guidelines often classify these patients as vulnerable to adverse outcomes, despite limited long-term comparative data.
To address this gap, the investigators used the Danish National Patient Registry to identify 21,132 patients who were evaluated for stable angina between 2003 and 2021 and were found to have no or only mild coronary artery disease on angiography. These individuals were matched by age and sex to 105,660 people from the general population with no known history of coronary artery disease. The median age of participants was 62 years, and just under 45% were men. Patients were followed for a median of 10.7 years, with outcomes assessed up to 15 years.
The study led to the following findings:
- At baseline, patients with ANOCA had higher rates of diabetes, hypertension, chronic lung disease, heart failure, and atrial fibrillation than the matched general population.
- They were more frequently treated with antithrombotic agents, statins, antihypertensive drugs, and glucose-lowering therapies, indicating a greater burden of cardiovascular risk factors.
- Over 15 years, the cumulative incidence of myocardial infarction was identical in ANOCA patients and the general population (3.5% in both groups).
- Ischemic stroke occurred slightly more often in patients with ANOCA compared with the general population.
- Overall mortality was marginally lower among ANOCA patients than in the matched general population.
- Cancer and cardiovascular disease were the leading causes of death in both cohorts.
- Men and patients aged 75 years or older with ANOCA had the lowest relative risks compared with their counterparts in the general population.
- Patients younger than 55 years with ANOCA showed higher rates of myocardial infarction, ischemic stroke, and death, suggesting a higher-risk subgroup.
The authors note that the registry data did not allow for detailed exploration of the underlying mechanisms responsible for ANOCA, such as coronary microvascular dysfunction or vasospasm. Nevertheless, the findings provide valuable long-term evidence indicating that ANOCA, as a diagnostic category, does not uniformly confer excess cardiovascular risk.
"Overall, the study suggests that long-term prognosis in ANOCA is more nuanced than previously assumed and varies by age and sex. These results may help clinicians refine risk stratification, avoid unnecessary alarms in older patients, and focus attention on younger individuals who may warrant more intensive follow-up and tailored management strategies," the authors concluded.
Reference:
Olesen KKW, Madsen M, Würtz M, et al. 15-year cardiovascular risk in patients with angina without obstructive coronary arteries. JACC Cardiovasc Interv. 2025;Epub ahead of print.
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