Small Vessel Disease

Small vessel disease, also called coronary microvascular disease or small vessel heart disease, is a condition in which small arteries in your heart get narrowed.

Small vessel disease occurs most commonly in diabetic or hypertensive people and in women, even though anyone can be affected.

Signs and symptoms similar to that of heart disease, such as chest pain (angina), may be experienced.  If you have a set of symptoms that indicate heart disease but there is no evidence of narrowing of large arteries, small vessel disease is confirmed. 

Small vessel disease is hard to detect but once detected, it is curable.

The signs and symptoms of small vessel disease are similar to that of other heart conditions and include:

• Squeezing chest pain that often radiates to your left arm, neck, shoulder, upper back or jaw.
• Chest pain precipitated by emotional stress and daily activities.
• Shortness of breath.
• Extreme tiredness.
• Difficulty sleeping.

If the symptoms of coronary artery disease do not disappear even after treatment with angioplasty and stents, incidence of small vessel disease is suspected.

When to see a doctor? 

Seek immediate medical care if you experience chest pain that often radiates to one of both of your arms or your neck, shortness of breath, sweating and dizziness.

Small Vessel Disease is caused when small arteries in your heart get narrowed.

Larger arteries in your heart pump most of blood through your heart and during stressful activities, small blood vessels expand to provide extra blood to your heart. When at rest, these vessels contract.

Atherosclerosis, a condition where fatty acids gets deposited in the arteries, can cause narrowing of large vessels which in turn puts more load on the small vessels during stressful activities. When these small vessels lose their ability to expand due to endothelial dysfunction, typical symptoms of heart disease become apparent as it reoccurs inadequate oxygen supply.

Making a diagnosis of small vessel disease is done by performing several tests and procedures.

If you previously had heart disease or chest pain, your primary care doctor may refer you to a cardiologist (who treats disorders of the cardiovascular system). 

How to prepare yourself for the visit?

Getting prepared for the visit can optimize the therapy and help make the visit more fruitful.

List out all the symptoms.

Write down your key medical information. 

Write down the names of all your medications, vitamins or supplements. 

Make a list of the questions to ask your doctor. Some typical questions can be: 

• What could be probable cause of my symptoms? 
• What tests do I need? 
• Is small vessel disease temporary or long lasting? 
• What are my treatment options and side effects of each option? 
• Do I have any alternatives to the primary approach that you're suggesting? 
• Do I need to follow dietary restrictions? 

What your doctor wants to know?

A clear talk with your doctor can optimize the therapy and improve the outcomes. Prepare yourself to answer some essential questions from your doctor. Your doctor might ask you typical questions like: 

• When did you first notice the symptoms and how severe are they? 
• Have your symptoms been continuous or occasional? 
• Have you noticed any changes in your symptoms? 
• Do your symptoms become worse when under physical stress? 
• Have you been diagnosed with high blood pressure, diabetes or high cholesterol? 
• Does anyone in your family have had heart disease?

Both large vessel coronary artery disease and small vessel disease share many signs and symptoms. Before recommending tests for small vessel disease, your doctor can suggest tests to rule out chances of large vessel coronary artery disease. Your diagnosis for small vessel disease starts with physical examination followed by a thorough evaluation of your medical history and family history of heart disease. The level of cholesterol in your blood is checked to determine whether the clogging of your arteries and chest pain is caused by cholesterol. Following tests may be performed to diagnose small vessel disease:

• Stress test with imaging: It involves imaging your heart while you are under some physical stress like running or riding a bicycle. Ultrasound images (echocardiogram) or nuclear imaging scans examine whether your heart is functioning properly. The doctor will also evaluate the amount of blood that is supplied to your heart muscle.
• Positron emission tomography (PET): This advanced test determines the quantity of blood that is delivered to other body parts. 
• Magnetic resonance imaging (MRI): MRI uses magnetic field and radio waves to create detailed images of your heart to detect narrowing of larger arteries.
• Endothelial function test: This is a non-invasive test which gives a measure of how well your endothelial cells, cells that line your blood vessels, are working. This test, however, doesn’t give conclusive results.
• Coronary angiogram: X-ray visible dye is injected into arteries through a catheter (long, thin tube) that is inserted into an artery commonly that of your groin or arms. The catheter is then passed up to the arteries of your heart where X-ray image is taken to detect whether the major arteries in your heart are narrowed. Additional test to detect small vessel disease is performed if your doctor can't locate any obstruction in your major arteries. 
• Endothelial dysfunction test: It is an invasive test that determines blood flow through the small blood vessel. 

The aim of treatment for small vessel disease is to control the narrowing of your small blood vessel and hence prevent the possibility of a heart attack. Your doctor may suggest: 

• Nitroglycerin: Nitroglycerin dilates coronary arteries and decreases oxygen demand of heart's muscle. Both of these effects reduce the chest pain. The nitroglycerin is available as tablets, sprays and transdermal patches.
• Ranolazine: It changes the level of sodium and calcium which helps to relieve chest pain.
• Beta blockers: Beta blockers decrease your heart rate and blood pressure. This in turn decreases oxygen demand of heart’s muscle.
• Calcium channel blockers: They dilate the coronary arteries which increases the supply of blood to the heart. They also reduce blood pressure.  
• Statins: Statins lower the blood cholesterol level thereby reducing the incidences of atherosclerosis. They also dilate coronary arteries and treat blood vessel damage. 
• Angiotensin-converting enzyme (ACE) inhibitors: These pressure lowering agents relax blood vessels and facilitate blood flow.
• Angiotensin II receptor blockers (ARBs): They dilate your blood vessel and control your blood pressure thus facilitating blood flow. 
• Aspirin: Aspirin is a pain drug that helps to control inflammation and prevent blood clots from forming.

You will frequently need to be examined if you have small vessel disease. The frequency of visits to your doctor for checkups will be determined by your doctor based on the severity of your condition. 

There is no certain way to prevent small vessel disease. However, managing risk factors, such as, high blood pressure, high cholesterol and obesity, can prevent its occurrence.  Following tips may reduce your risk:

• Quit smoking or using other tobacco products.
• Avoid oily foods. Take a diet that contains whole grains, lean meat and fruits, and vegetables.
• Cut down on salt and fat intake. 
• Be active: Exercise regularly. Exercise strengthens your heart muscle and maintains the blood flow in your arteries. Physical activity is a key factor in reducing your risk of diabetes, high cholesterol level and high blood pressure. 
• Keep your blood cholesterol in check: A regular check can give you an idea of level of cholesterol in your blood. If the level of bad cholesterol in your blood is elevated, you may need to change the diet or need to take medications prescribed by the doctors. 
• Maintain a healthy weight: Healthy weight is associated with low risk of small vessel disease. 
• Control your blood pressure: Your blood pressure may need to be measured regularly if you have blood pressure problems or had heart disease in the past.
• Control your blood sugar: If you are a diabetic, manage your blood sugar level. Talk to your doctor about the amount of blood sugar level that is appropriate for you.

A few alternative remedies exist for small vessel disease.

Nutritional supplement that may be given to people with small vessel disease are:

• Coenzyme Q10: This coenzyme present in your body may be used to improve circulation. The maximum daily dose is 200 mg. 
• L-arginine: It is an amino acid that can be used to expand your blood vessels and relieve symptoms of small vessel disease. Note that this is contraindicated in people who have had heart attack in the past. 

Discuss with your doctor about the benefits of taking dietary supplement. Also, ask your doctor whether those supplements interact with the medications you are taking. 

There are several risks and complications associated with small vessel disease.

Risks

• Age: Men above 45 and women above 55 are at higher risk 
• Tobacco use: If you use tobacco, you are at an increased risk of developing small vessel disease.
• Obesity: If you are obese or lead a sedentary lifestyle, your risk is higher.
• Sex: If you are female, have estrogen deficiency as well as polycystic ovarian syndrome, your risk of having small vessel disease increases.
• Conditions like elevated blood cholesterol level, hypertension and diabetes increases the likelihood of having small vessel disease

Complications

• Sudden narrowing of coronary artery 
• Heart attack
• Congestive heart failure