Chest pain can be frightening. Naturally, many people worry that it could be a heart attack or blocked heart arteries.

When a CT coronary angiogram shows no significant blockages, it is reassuring. But for some people, the chest pain doesn’t go away. They continue to experience symptoms during exercise or everyday activities, despite being told that their heart looks “normal.”

So what happens when the pain is real, but routine heart tests don’t provide an answer?

Sometimes, the problem isn’t in the large heart arteries at all.

A Real Patient’s Story

A 53-year-old woman came to see Dr Pinakin after experiencing chest pain on exertion for several years.

She had previously undergone medical assessments and was reassured that everything was normal. After relocating to Singapore, she sought another opinion because her symptoms persisted.

A CT coronary angiogram showed no significant blockages in her heart arteries. For many patients, this would be considered reassuring.

However, her symptoms continued to suggest that something wasn’t right. Rather than dismissing the pain, Dr Pinakin looked deeper.

Can You Have Chest Pain Even If Your Heart Scan Is Normal?

Yes. A normal CT coronary angiogram means there are no significant blockages in the major heart arteries, but it does not rule out every possible heart-related cause of chest pain.

Some patients continue to experience:

• Chest pain during exercise
• Chest tightness
• Breathlessness with exertion
• Reduced exercise tolerance

 

When symptoms persist despite normal imaging, further evaluation may be needed to identify less common causes.

The Heart Has Large Arteries and Tiny Blood Vessels

Think of your heart’s blood supply like a road network.

The large coronary arteries are like major highways, carrying blood to the heart muscle. These are the blood vessels that can be clearly seen on a CT coronary angiogram or a standard coronary angiogram.

But the heart also relies on an extensive network of tiny blood vessels, known as the microcirculation. These vessels are too small to be seen on routine heart scans, yet they play a vital role in delivering oxygen-rich blood to the heart muscle.

Sometimes, these tiny blood vessels do not function as they should. Although the major arteries appear normal, reduced blood flow through the microcirculation can still cause chest pain, particularly during exercise or physical activity.

What Is Coronary Microvascular Dysfunction?

One condition that can cause this is coronary microvascular dysfunction.

Coronary microvascular dysfunction affects the heart’s smallest blood vessels, which may not widen or respond normally when the heart needs more blood. As a result, the heart muscle may not receive enough oxygen during physical activity, leading to symptoms such as chest pain or breathlessness.

Coronary microvascular dysfunction is more commonly seen in postmenopausal women, although it can affect other patients as well.

Why Routine Heart Tests Can Sometimes Miss It

Routine heart tests are excellent at detecting many heart conditions, particularly blockages in the major coronary arteries.

However, they cannot directly assess how well the heart’s tiny blood vessels are functioning.

This means that some patients may continue to experience genuine heart-related symptoms, even though their scans appear normal. In these situations, specialised testing may help provide answers.

Looking Deeper with Advanced Coronary Assessment

Because the patient’s symptoms persisted despite a normal CT coronary angiogram, Dr Pinakin recommended an intracoronary physiology assessment.

Performed during a coronary angiogram, this specialised procedure uses a thin pressure wire to measure blood flow within both the larger heart arteries and the heart’s microcirculation.

Unlike routine imaging, it helps determine whether the heart muscle is receiving enough blood and whether the tiny blood vessels are functioning normally.

In this patient’s case, the test confirmed coronary microvascular dysfunction, providing a clear explanation for her symptoms and allowing treatment to begin.

Why Getting the Right Diagnosis Matters

For patients, receiving the correct diagnosis is about much more than simply naming a condition.

It means:

• Understanding why symptoms are happening
• Receiving appropriate treatment
• Avoiding unnecessary uncertainty
• Feeling reassured that symptoms have been taken seriously

 

Chest pain should not automatically be dismissed simply because an initial heart scan is normal. While many patients do not have serious heart disease, some may have conditions that require further investigation and treatment.

Dr Pinakin’s Approach to Persistent Chest Pain

Every patient is different, and not all chest pain follows a textbook pattern. Patients often value Dr Pinakin’s approach because it focuses on:

Listening to the Whole Story

Understanding your symptoms, concerns, and how they affect your daily life, not just your test results.

Looking Beyond Routine Tests

Knowing when advanced investigations may be appropriate if symptoms and initial findings do not match.

Finding the Cause

Using contemporary diagnostic techniques to identify heart conditions that standard imaging may not detect.

Personalised Heart Care

Tailoring treatment to the underlying cause, with the goal of improving symptoms and protecting long-term heart health.

 

When Should You See a Cardiologist?

You should consider seeing a cardiologist if:

• You continue to experience chest pain despite normal heart tests
• Your symptoms occur during exercise or physical activity
• Your chest pain keeps coming back
• You have other cardiovascular risk factors, such as diabetes, high blood pressure, or high cholesterol
• You would like a second opinion because your symptoms remain unexplained

 

Persistent chest pain deserves careful assessment. While many cases are not caused by blocked arteries, identifying the underlying cause is an important step towards receiving the right treatment.

 

If your symptoms continue despite being told your heart tests are “normal,” a cardiologist such as Dr Pinakin can assess whether more specialised investigations are appropriate to help find the cause of your symptoms.