NHCS Introduces New Approaches To Detect “Hidden” Heart Disease In Older Adults

• Under its CRANE¹ programme, the National Heart Centre Singapore expands diagnostic capabilities to identify "hidden" heart conditions that disproportionately affect older adults, women and people with diabetes.
• New functional angiography and advanced cardiac imaging address conditions that affect more than 1 in 5 angina patients yet often go undiagnosed. 

Singapore, 3 June 2026 – For three years, Ms Frieda Matilda Desker lived with chest pain that standard tests could not fully explain. After her first episode in 2022, an angiogram showed severely narrowed heart arteries, and she underwent a successful angioplasty. However, the tightness returned in subsequent years. Repeated scans came back normal and repeated visits to her general practitioner brought no answers.

In 2025, after referral to the National Heart Centre Singapore (NHCS), she was offered to undergo functional coronary angiography, a more sensitive test that measures how the heart's blood vessels behave rather than how they look on scans. She was diagnosed with coronary vasospasm, a condition in which the heart arteries suddenly tighten and restrict blood flow. With targeted medication, Ms Frieda’s symptoms have largely resolved. 

New approaches under the CRANE programme

Her experience reflects a wider problem in diagnosing the root cause of angina, the medical term for chest pain caused by reduced blood flow to the heart. Stable angina is classically described as discomfort or tightness at the centre of the chest, which is worsened by exercise and relieved by rest or glycerin trinitrate. Data from the Singapore Cardiac Data Bank shows that 22 per cent of patients with angina have no major blockage in their heart arteries on standard angiograms. The condition, known as ANOCA (Angina with Non-Obstructive Coronary Arteries^2,3,4.), disproportionately affects older adults, women^5,6 and individuals with diabetes. When the cause remains unidentified, patients often experience recurring symptoms, repeat hospital visits and reduced quality of life.

To close this diagnostic gap, NHCS is strengthening care for suitable older adults through two new approaches under its CRANE (Cardiovascular Ageing and Longevity) Programme¹, launched in 2025 as Asia-Pacific's first comprehensive cardiovascular ageing initiative. Both approaches are offered to patients whose symptoms or condition cannot be fully explained by standard testing and target a long-standing blind spot: heart disease that does not show up on routine investigations but progressively erodes quality of life.  

(1)  Functional coronary angiography: Finding what standard scans miss

Standard coronary angiography looks for narrowing in the major heart arteries. It is effective for most patients but cannot detect problems in smaller blood vessels or sudden arterial spasms that account for symptoms in some patients. Functional coronary angiography is performed during a standard angiogram, using specialised pressure wires and medications to measure blood flow and pressure within the coronary arteries, including the microscopic vessels invisible to standard imaging.

The test is not a first-line investigation. It is offered to patients who, after specialist assessment, have unexplained angina symptoms despite normal results on standard scans, or whose symptoms persist despite treatment. The European Society of Cardiology’s latest international clinical guidelines 2024 recommend functional coronary angiography in patients with unexplained chest pain², and several trials have found that the test leads to an improved quality of life in this group of patients^7,8. While elements of the test have been available in selected settings in Singapore, NHCS is now establishing it as a structured, routine service within its dedicated cardiovascular ageing programme, underscoring the timeliness of this approach in better addressing ANOCA. Since the launch of CRANE, NHCS has performed more than a hundred functional coronary angiographies. 

“Functional coronary angiography is not a test for everyone with chest pain. It is offered to a specific group of patients whose angina cannot be fully explained by standard investigations, often after repeated tests. Patients with ANOCA often spend years moving between clinics, undergoing repeated tests, and being told nothing is wrong. That experience is exhausting,” said Assistant Professor Keh Yann Shan, Consultant, Department of Cardiology, NHCS, who is currently working with the interventional cardiology team to integrate the approach into routine clinical practice. “Functional coronary angiography allows us to give patients an actual diagnosis, and from there, a treatment that works.”

(2) MOSAIC: Spotting heart muscle decline earlier

The second approach, the MOSAIC (Multiparametric Heart-Muscle Imaging) Programme, builds on echocardiography, the ultrasound scan routinely used to assess how well the heart pumps. The MOSAIC applies advanced echocardiography techniques that assess the heart and the muscular system simultaneously, providing early insights into heart muscle quality at the tissue level. This enables intervention before significant muscle loss occurs, a key marker of frailty in older adults.

Like functional coronary angiography, MOSAIC is offered to patients identified through clinical assessment, including those with risk factors for age-related heart muscle decline, rather than as a general screening test. Its purpose is to enable earlier, more targeted intervention before significant muscle loss occurs. 

Why it matters now 

Singapore is among the world's most rapidly ageing societies, with one in four residents projected to be aged 65 and above by 2030. Older adults often present with atypical symptoms or heart conditions that elude standard testing, requiring more sensitive diagnostic tools and more personalised care pathways. 

“Through CRANE, NHCS is shifting cardiovascular care from treating advanced illness towards detecting disease earlier, understanding symptoms more precisely and helping patients maintain quality of life as they age,” Associate Professor Angela Koh, Director, CRANE, and Senior Consultant, Department of Cardiology, NHCS. “The approaches are designed to complement, not replace, standard cardiac care. They give our specialists better tools for patients who need them most.” 

“Heart disease in older adults is not always what it appears to be on a standard scan,” said Professor Yeo Khung Keong, Chief Executive Officer, NHCS. “Our job is to keep pace with that complexity, while ensuring that the right tests are used for the right patients. Functional coronary angiography and MOSAIC are practical examples of what CRANE was built to deliver: care designed around the patient in front of us, not the textbook.”  

References:

1. National Heart Centre Singapore Launches Region’s First Comprehensive Cardiovascular Ageing And Longevity Initiative        
2. Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024;45(36):3415-537.3.     
3. Samuels BA, Shah SM, Widmer RJ, Kobayashi Y, Miner SES, Taqueti VR, et al. Comprehensive Management of ANOCA, Part 1-Definition, Patient Population, and Diagnosis: JACC State-of-the-Art Review. J Am Coll Cardiol. 2023;82(12):1245-63.    
4.  Ford TJ, Stanley B, Good R, Rocchiccioli P, McEntegart M, Watkins S, et al. Stratified Medical Therapy Using Invasive Coronary Function Testing in Angina: The CorMicA Trial. J Am Coll Cardiol. 2018;72(23 Pt A):2841-55.
5. Shaw LJ, Merz CN, Pepine CJ, Reis SE, Bittner V, Kip KE, et al. The economic burden of angina in women with suspected ischemic heart disease: results from the National Institutes of Health--National Heart, Lung, and Blood Institute--sponsored Women's Ischemia Syndrome Evaluation. Circulation. 2006;114(9):894-904.
6. Aldiwani H, Zaya M, Suppogu N, Quesada O, Johnson BD, Mehta PK, et al. Angina Hospitalization Rates in Women With Signs and Symptoms of Ischemia But no Obstructive Coronary Artery Disease: A Report from the WISE (Women's Ischemia Syndrome Evaluation) Study. J Am Heart Assoc. 2020;9(4):e013168.
7. Boerhout CKM, Namba HF, Liu T, Beijk MAM, Damman P, Meuwissen M, et al. Coronary function testing vs angiography alone to guide treatment of angina with non-obstructive coronary arteries: the ILIAS ANOCA trial. Eur Heart J. 2025;46(42):4396-406.
8. Ford TJ, Stanley B, Sidik N, Good R, Rocchiccioli P, McEntegart M, et al. 1-Year Outcomes of Angina Management Guided by Invasive Coronary Function Testing (CorMicA). JACC Cardiovasc Interv. 2020;13(1):33-45.