To evaluate persistent angina in stable angina pectoris with no obstructive coronary artery disease (CAD) compared to obstructive CAD and its relation to long-term anxiety, depression, quality of life (QOL), and physical functioning.

We invited 357 patients (men = 191; women = 166; response rate 83 %) with no prior cardiovascular disease who had a first-time coronary angiography (CAG) in 2008–2009 due to suspected stable angina to participate in a questionnaire survey in 2011 with the Seattle Angina Questionnaire and the Hospital Anxiety and Depression Scale as key elements. Long-term persistent angina (i.e., symptoms at least once a month) was present in 64 % of patients with diffuse non-obstructive CAD (1–49 % stenosis), 49 % of patients with normal coronary arteries (0 % stenosis), and 41 % of patients with obstructive CAD (≥50 % stenosis) (P = 0.01). Depression and anxiety were more common in patients with persistent angina: 24 versus 7 % (P < 0.001) reported HADS-Depression-scores >7 and 42 versus 21 % (P < 0.001) reported HADS-Anxiety-scores >7. In multivariate regression models, persistent angina was associated with depression (OR 4.3, 95 % confidence interval (CI) 1.9–9.6, P < 0.001), anxiety (OR 2.9, 95 % CI 1.6–5.1, P < 0.001), the severity of persistent angina with impaired physical functioning (P < 0.001), and QOL (P < 0.001); whereas outcomes were not related to age, gender, or degree of CAD.

The study indicates higher prevalence of persistent angina in patients with diffuse non-obstructive CAD or normal coronary arteries than in patients with obstructive CAD. Persistent angina symptoms were associated with long-term anxiety, depression, impaired physical functioning, and QOL irrespective of the degree of CAD. Contrary to common perception, excluding obstructive CAD in stable angina does not ensure a favorable disease course, and further risk stratification and treatment strategies are warranted.