With Sarah Birkhoelzer, Oxford University Hospitals, Oxford - UK, and Edgar Argulian, Mount Sinai Morningside, New York - USA.

In this episode, we explore a study by Edgar Argulian published in European Heart Journal – Imaging Methods and Practice (2025), which challenges the assumption that myocardial ischaemia on exercise echocardiography (ExE) is benign when coronary angiography shows no obstructive coronary artery disease (CAD).

The study retrospectively analysed 84 patients with exercise-induced ischaemia but no obstructive CAD, subdividing them into those with normal coronaries (iNC) and non-obstructive CAD (iNOCAD).

Over a median 3.2-year follow-up, patients with ischaemia—especially those with iNC—faced significantly higher rates of acute chest pain and adverse cardiovascular outcomes compared to matched controls. Notably, women were overrepresented in the iNC group and were less likely to be on cardioprotective medications.

The findings suggest that what has often been labelled as a "false positive" ExE may in fact reflect underlying microvascular dysfunction, endothelial abnormalities, or vasospasm—particularly in women.

This study calls for more tailored evaluation, vigilant follow-up, and optimized treatment strategies in patients with symptomatic ischaemia despite "normal" angiograms. Tune in as we unpack the implications for clinical practice and why we should stop dismissing these findings as incidental. -