Date of Award

January 2024

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Samit Shah


Background: Ischemic heart disease (IHD) is a leading cause of morbidity and mortality in women. Up to two-thirds of women with IHD suffer from ischemia with no obstructive coronary artery disease (INOCA), which includes endotypes such as microvascular dysfunction and vasospasm. Due to a lack of clear prognostic data, INOCA has historically been viewed as a benign condition and many women have been dismissed from cardiovascular care, despite refractory symptoms and a risk for adverse outcomes. The objective of this qualitative study is to utilize structured interviews to formally characterize the experience of women with INOCA diagnosed with invasive coronary function testing.

Methods: We enrolled 50 women with INOCA who underwent clinically-indicated invasive coronary function testing. Structured interviews were performed to elicit symptom characteristics, physical and functional limitation, and perception of illness. Data extracted from the interviews was analyzed using the constant comparison method to determine themes among women with INOCA.

Results: The most common symptoms in our sample included chest pain (n=47, 94%), radiation of chest pain to other areas (43, 86%), dyspnea (43, 86%), fatigue (40, 80%), and abnormal heart rhythms (33, 66%). Most participants experienced symptoms daily (29, 58%) and reported severe symptoms (40, 80%). They expressed limitation to instrumental activities of daily living (35, 70%), social life (33, 66%), hobbies (30, 60%), work (24, 48%), and travel (11, 22%). Many reported feelings of anxiety (47, 94%), depression (41, 82%), and frustration (25, 50%), a sense of foreshortened future (33, 66%), a feeling of invalidation by providers and loved ones (33, 66%), and difficulty finding a diagnosis (40, 80%). After receiving a diagnosis, participants reported positive outcomes such as reduced stress and better understanding of disease management.

Conclusion: Women with INOCA have significant impairment in quality of life due to frequent anginal symptoms. Feelings of invalidation were common, and many participants reported multiple incorrect diagnoses. After receiving a diagnosis, they reported reduced stress, improvement in illness perception, and hope for improved health in the future. These findings demonstrate the importance of recognizing INOCA and incorporating advances such as physiology-guided medical therapy into routine practice.


This is an Open Access Thesis.

Open Access

This Article is Open Access