CLINICIAN’S CORNERCLINICAL REVIEW Angina With “Normal ” Coronary Arteries A Changing Philosophy

EACH YEAR, MANY WOMEN AREtold that they have no signifi-cant heart disease followingdemonstration of “normal ” or near-normal coronary arteries after coronary angiography and are offered no treatment beyond reassurance.1New data suggest that this approachmay no longer be appropriate. Specifically, pa-tients with chest pain and normal or near-normal coronary angiograms are a group in which the prognosis is not as benign as previously thought. METHODS We searched English-language stud-ies onMEDLINE and theCochraneDa-tabase of Systematic Reviews from the database start dates to June 2004. Among the specific key words and phrases we used were pathophysiol-ogy, diagnosis and therapy of anginawith normal angiography; angina with nor-mal coronary arteries; cardiac syn-drome X, nonobstructive coronary dis-ease and variant angina; etiology of chest pain of non-cardiac origin; and endothe-lial dysfunction and prognosis. We also consulted reference lists of published articles and data frommeeting presen-tations. Evidence synthesis was based on cohort studies, registry data, and trial data. RESULTS Prevalence Normal, defined as no visible disease, or nonobstructive atherosclerotic coro-CME available online at www.jama.co