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Coronary ischemia, myocardial ischemia, or cardiac ischemia, is a medical term for a reduced blood flow in the coronary circulation through the coronary arteries.

Coronary ischemia is linked to heart disease, and heart attacks. Coronary arteries deliver oxygen-rich blood to the heart muscle. Reduced blood flow to the heart associated with coronary ischemia can result in inadequate oxygen supply to the heart muscle. When oxygen supply to the heart is unable to keep up with oxygen demand from the muscle, the result is the characteristic symptoms of coronary ischemia, the most common of which is chest pain. Chest pain due to coronary ischemia commonly radiates to the arm or neck. Certain individuals such as women, diabetics, and the elderly may present with more varied symptoms. If blood flow through the coronary arteries is stopped completely, cardiac muscle cells may die, known as a myocardial infarction, or heart attack.

Coronary artery disease (CAD) is the most common cause of coronary ischemia. Coronary ischemia and coronary artery disease are contributors to the development of heart failure over time. Diagnosis of coronary ischemia is achieved by an attaining a medical history and physical examination in addition to other tests such as electrocardiography (ECG), stress testing, and coronary angiography. Treatment is aimed toward preventing future adverse events and relieving symptoms. Beneficial lifestyle modifications include smoking cessation, a heart healthy diet, and regular exercise. Medications such as nitrates and beta-blockers may be useful for reducing the symptoms of coronary ischemia. In refractory cases, invasive procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) may be performed to relieve coronary ischemia.

Recently evidence has been found that ischemia can also occur without coronary obstruction (a condition known as INOCA - ischemia with no obstructed arteries). Other studies have found that Long COVID or post acute COVID syndrome is also associated with myocardial ischemia. Treatment for both conditions is similar to treatment for ischemia caused by CAD.

Hansen B, Holtzman JN, Juszczynski C, Khan N, Kaur G, Varma B, Gulati M. Ischemia with No Obstructive Arteries (INOCA): A Review of the Prevalence, Diagnosis and Management. Curr Probl Cardiol. 2023 Jan;48(1):101420. doi: 10.1016/j.cpcardiol.2022.101420. Epub 2022 Sep 30. PMID: 36183980.

Mohammad KO, Lin A, Rodriguez JBC. Cardiac Manifestations of Post-Acute COVID-19 Infection. Curr Cardiol Rep. 2022 Dec;24(12):1775-1783. doi: 10.1007/s11886-022-01793-3. Epub 2022 Nov 2. PMID: 36322364; PMCID: PMC9628458.

INOCA

INOCA is cardiac ischemia with no coronary artery obstruction. Approximately 3-4 million people have been diagnosed with this condition; with female diagnosis prevalent. Risk factors included female, advanced age, smoking, diabetes, hyperlipidemia, and inflammatory disease. Diagnosis of INOCA can begin with non-invasive testing to included PET with myocardial perfusion imaging (MPI) or stress cardiovascular magnetic resonance (CMR) imaging. However, final diagnosis must be made with cardiac angiography to make certain there is no occlusion.

Hansen B, Holtzman JN, Juszczynski C, Khan N, Kaur G, Varma B, Gulati M. Ischemia with No Obstructive Arteries (INOCA): A Review of the Prevalence, Diagnosis and Management. Curr Probl Cardiol. 2023 Jan;48(1):101420. doi: 10.1016/j.cpcardiol.2022.101420. Epub 2022 Sep 30. PMID: 36183980.

ISCHEMIA INVOLVING SARS-CoV2

Data involving cardiac ischemia resulting from post acute COVID syndrome (or Long COVID) is evolving. Various studies have been combined to show a significant percentage of patients presenting with myocardial ischemia post COVID infection (infection requiring hospitalization) with no documented prior history of coronary disease. Vaccination (with 2 doses) has been shown to decrease the risk of Long COVID in recent studies.

Mohammad KO, Lin A, Rodriguez JBC. Cardiac Manifestations of Post-Acute COVID-19 Infection. Curr Cardiol Rep. 2022 Dec;24(12):1775-1783. doi: 10.1007/s11886-022-01793-3. Epub 2022 Nov 2. PMID: 36322364; PMCID: PMC9628458.

Diagnosis[edit]

If coronary ischemia is suspected, a series of tests will be undertaken for confirmation. The most common tests used are an electrocardiogram, an exercise stress test, and a coronary angiography. A medical history will be taken, including queries about past incidence of chest pain or shortness of breath. A variety of laboratory tests may be ordered. An important laboratory test to determine if myocardial damage has occurred is a Cardiac Troponin value. Cardiac Troponin Serum Concentration Measurement Is Useful Not Only in the Diagnosis of Acute Cardiovascular Events. J Pers Med. 2024 Feb 21;14(3):230. doi: 10.3390/jpm14030230. PMID: 38540973; PMCID: PMC10971222. The duration and frequency of symptoms will be noted as will any measures taken to relieve the symptoms.

Symptoms and signs[edit]

A key symptom of coronary ischemia is chest pain or pressure, known as angina pectoris. Angina may present typically with classic symptoms or atypically with symptoms less often associated with heart disease. Atypical presentations are more common in women, diabetics, and elderly individuals. Angina may be stable or unstable. Unstable angina is most often associated with emergent, acute coronary syndromes. Goyal A, Zeltser R. Unstable Angina. 2022 Sep 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 28723029.