Coronary microvascular disease: The “Meeting Point” of Cardiology, Rheumatology and Endocrinology

Abstract

Background Exertional chest pain/dyspnea or chest pain at rest are the main symptoms of coronary artery disease (CAD), which are traditionally attributed to insufficiency of the epicardial coronary arteries. However, 2/3 of women and 1/3 of men with angina and 10% of patients with acute myocardial infarction have no evidence of epicardial coronary artery stenosis in X‐ray coronary angiography. In these cases, coronary microvascular disease (CMD) is the main causative factor. Aims To present the pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology. Materials‐Methods The pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology was evaluated. It includes impaired microvascular vasodilatation, which leads to inability of the organism to deal with myocardial oxygen needs and, hence, development of ischemic pain. CMD, observed in inflammatory autoimmune rheumatic and endocrine/metabolic disorders, brings together Cardiology, Rheumatology and Endocrinology. Causative factors include persistent systemic inflammation and endocrine/metabolic abnormalities influencing directly the coronary microvasculature. In the past, the evaluation of microcirculation was feasible only with the use of invasive techniques, such as coronary flow reserve assessment. Currently, the application of advanced imaging modalities, such as cardiovascular magnetic resonance (CMR), can evaluate CMD non‐invasively and without ionizing radiation. Results CMD may present with a variety of symptoms with 1/3 to 2/3 of them expressed as typical chest pain in effort, more commonly found in women during menopause than in men. Atypical presentation includes chest pain at rest or exertional dyspnea,but post exercise symptoms are not uncommon. The treatment with nitrates is less effective in CMD, because their vasodilator action in coronary micro‐circulation is less pronounced than in the epicardial coronary arteries. Discussion Although both classic and new medications have been used in the treatment of CMD, there are still many questions regarding both the pathophysiology and the treatment of this disorder. The potential effects of anti‐rheumatic and endocrine medications on the evolution of CMD need further evaluation. Conclusion CMD is a multifactorial disease leading to myocardial ischemia/fibrosis alone or in combination with epicardial coronary artery disease. Endothelial dysfunction/vasospasm, systemic inflammation, and/or neuroendocrine activation may act as causative factors and bring Cardiology, Rheumatology and Endocrinology together. Currently, the application of advanced imaging modalities, and specifically CMR, allows reliable assessment of the extent and severity of CMD. These measurements should not be limited to “pure cardiac patients”, as it is known that CMD affects the majority of patients with autoimmune rheumatic and endocrine/metabolic disorders.

Visualization of Concurrent Epicardial and Microvascular Coronary Artery Disease in a Patient with Systemic Lupus Erythematosus by Magnetic Resonance Imaging

“…Coronary microvascular dysfunction (CMVD) is the result of coronary artery dysregulation by endothelial and nonendothelial factors. 18 CMVD is usually transient and the myocardial territory affected is limited and presents in a patchy distribution. 19 The diagnosis of CMVD relies on the exclusion of existing epicardial CAD and vasospasm by ICA, along with the detection of stress induced myocardial perfusion defects via contrast enhanced CMR, positron emission tomography, or contrast enhanced echocardiography.…”

An Examination of Clopidogrel in the Treatment of Coronary Microvascular Disease

“…Six studies within the review do not report the usage of this treatment option which may suggest that while dual antiplatelet therapy is what is often used to help patients with microvascular issues, there may be instances where it is not the most conducive method of obtaining the desired outcome [9,[11][12][13]16,18]. For instance, for patients who are allergic or intolerant to aspirin, dual therapy may not be a viable option as the treatment method commonly requires the usage of both aspirin and clopidogrel to obtain the best effect [1][2][3]. Another example of this would be instances where glycemic control is being used to reduce CMD issues in hypoglycemic diabetic patients [9].…”

“…This article examines coronary microvascular disease (CMD), a subset of coronary artery disease. CMD is a disorder that affects the walls and inner lining of coronary microvessels [ 2 ]. Specifically, this illness causes constriction of the tiny blood arteries around the heart.…”

“…Specifically, this illness causes constriction of the tiny blood arteries around the heart. Coronary microcirculation is hindered by these constricted blood channels, resulting in unfavorable cardiovascular outcomes such as myocardial infarction (MI) [2]. Smoking, hypertension, and low highdensity lipoprotein (HDL) cholesterol levels are risk factors that can lead to this disease [3][4][5][6][7].…”

Pharmacological Treatment of Diabetic and Non-Diabetic Patients With Coronary Artery Disease in the Real World of General Practice

“…Type 2 diabetes mellitus (T2DM) is a complex metabolic disease which multiplies the likelihood of developing macrovascular complication, such as coronary artery diseases (CAD) and peripheral arterial disease (PAD) ( Shah et al, 2015 ; Joseph et al, 2020 ; Singh et al, 2021 ; Markousis-Mavrogenis et al, 2022 ), and microvascular complication, mainly nephropathy and retinopathy ( Altavilla et al, 2009 ; Saputro et al, 2021 ; Xiong et al, 2021 ; Markousis-Mavrogenis et al, 2022 ).…”