Because large vessel coronary artery disease and small vessel disease have the same signs and symptoms, it's likely your doctor will check the main arteries in your heart first. If no problems are found, then your doctor might test for small vessel disease.

To diagnose small vessel disease, your doctor will also ask you about your medical history and family history of heart disease. During your exam your doctor will likely check for high cholesterol and diabetes.

The tests for small vessel disease are similar to those for other types of heart disease and include:

  • Stress test with imaging. You'll either exercise on a treadmill or a bike or take a medication that raises your heart rate to mimic the effect of exercise.

    Images will be taken of your heart using ultrasound images (echocardiogram) or with nuclear imaging scans to assess the blood flow to your heart muscle.

  • Coronary angiogram. This test helps doctors determine if the main arteries to your heart are blocked. A liquid dye is injected into the arteries of your heart through a catheter — a long, thin tube that's fed through an artery, usually in your groin, to arteries in your heart. As the dye fills your arteries, they become visible on X-ray and video.
  • Positron emission tomography (PET). This test, which uses a radioactive dye and medication, can show your heart's blood flow to other parts of your body. After the dye is injected, you lie in a doughnut-shaped machine to have images taken of your heart.
  • CT scan or CT angiography (CTA) scan. A CT scan combines a series of X-rays taken from different angles with computer processing to create detailed images. A CTA scan uses a contrast dye injected through a line in your arm or hand to assess your blood vessels.
  • MRI. In a cardiac MRI, you lie on a table inside a long tubelike machine that produces a magnetic field. MRI produces images of your heart that enables your doctor to see blockages.

If your doctor can't find blockages in your main arteries based on these tests, you might have an additional test to check for blockages in the smaller arteries of your heart:

  • Endothelial dysfunction test. The endothelium is a layer of cells that line all of your blood vessels. When the endothelium isn't functioning well, the blood vessels can't expand properly.

    To test endothelial function, a wire is threaded through a catheter inserted in one of your coronary arteries and a medication is injected into the artery that causes the small vessels in your heart to open. Then the blood flow through those vessels is measured.

    This invasive test is the surest way to detect small vessel disease. Researchers are looking at noninvasive methods of endothelial function.


The treatment for small vessel disease involves medications to control the narrowing of your small blood vessels that could lead to a heart attack and to relieve pain. Your doctor could prescribe:

  • Nitroglycerin. Nitroglycerin tablets, sprays and patches can ease chest pain by relaxing your coronary arteries and improving blood flow.
  • Beta blockers. These drugs, such as propranolol (Inderal, Innopran XL, others) and bisoprolol (Zebeta), slow your heart rate and decrease your blood pressure.
  • Calcium channel blockers. Drugs such as verapamil (Verelan, Calan, others) and diltiazem (Cardizem, Diltzac, others) relax the muscles around your coronary arteries and cause the vessels to open, increasing blood flow to your heart. They also control high blood pressure.
  • Statins. Medications such as atorvastatin (Lipitor) and simvastatin (Zocor) help lower cholesterol, which contributes to the narrowing of your arteries. Statins also help relax the blood vessels of your heart and treat blood vessel damage.
  • Angiotensin-converting enzyme (ACE) inhibitors. Medications such as benazepril (Lotensin) and lisinopril (Prinivil, Zestril) help open your blood vessels and lower your blood pressure.
  • Angiotensin II receptor blockers (ARBs). Medications such as azilsartan (Edarbi) and losartan (Cozaar) relax your blood vessels, which lowers your blood pressure and makes it easier for your heart to pump blood.
  • Ranolazine (Ranexa). This medication eases chest pain by altering sodium and calcium levels.
  • Aspirin. Aspirin can limit inflammation and prevent blood clots.

If you're diagnosed with small vessel disease, you'll need to see your doctor regularly for checkups. Your doctor will determine how often you'll need to be examined, depending on the severity of your condition.

Alternative medicine

A dietary supplement that may be helpful for people with small vessel disease is L-arginine. This amino acid that's normally used by the body to help metabolize protein may help treat symptoms of small vessel disease by relaxing your blood vessels. This therapy shouldn't be used in anyone who's already had a heart attack.

Talk to your doctor before adding a supplement to your treatment to ensure that it won't interfere with medications you take.

Preparing for your appointment

If you've had chest pains or other symptoms of heart disease, your primary care provider will likely refer you to a doctor trained in treating disorders of the heart and circulatory system (cardiologist).

Here's some information to help you get ready for your appointment.

What you can do

When you make the appointment, ask if there's anything you need to do in advance, such as fasting before a specific test. Make a list of:

  • Your symptoms, including any that seem unrelated to the reason for your appointment
  • Key personal information, including major stresses; recent life changes; your and your family's medical history, especially history of heart disease, high blood pressure, diabetes and high cholesterol
  • All medications, vitamins or other supplements you take, including the doses
  • Questions to ask your doctor

Take a family member or friend along, if possible, to help you remember the information you're given.

For small vessel disease, basic questions to ask your doctor include:

  • What's likely causing my symptoms?
  • Other than the most likely cause, what are other possible causes for my symptoms?
  • What tests do I need?
  • Is my condition likely temporary or chronic?
  • What's the best course of action?
  • What are the alternatives to the primary approach you're suggesting?
  • I have these other health conditions. How can I best manage them together?
  • Are there restrictions I need to follow?
  • Should I see a specialist?
  • Are there brochures or other printed material I can have? What websites do you recommend?

Don't hesitate to ask other questions.

What to expect from your doctor

Your doctor is likely to ask you questions, such as:

  • When did your symptoms begin?
  • Have your symptoms been continuous or occasional?
  • How severe are your symptoms? Have your symptoms worsened?
  • Do your symptoms worsen when you're active?
  • Does anything make your symptoms better?
March 06, 2018
  1. Coronary microvascular disease. National Heart, Lung, and Blood Institute. http://www.nhlbi.nih.gov/book/export/html/4939. Accessed Jan. 21, 2016.
  2. Chaudhary I. Cardiac syndrome X: Angina pectoris with normal cardiac arteries. http://www.uptodate.com/home. Accessed Jan. 21, 2016.
  3. Crea F, et al. Coronary microvascular dysfunction: An update. European Heart Journal. 2014;35:1101.
  4. Lin CD, et al. Coronary microvascular function and beyond: The crosstalk between hormones, cytokines, and neurotransmitters. International Journal of Endocrinology. 2015;2015:1.
  5. Dean J, et al. Coronary microvascular dysfunction: Sex-specific risk, diagnosis and therapy. Nature Review Cardiology. 2015;12:406.
  6. Vizzardi E, et al. Noninvasive assessment of endothelial function: The classic methods and the new peripheral arterial tonometry. Journal of Investigative Medicine. 2014;62:856.
  7. Gerber TC, et al. Noninvasive coronary imaging with cardiac computed tomography and cardiovascular magnetic resonance. http://www.uptodate.com/home. Accessed Feb.1, 2016.


Associated Procedures