Physiological Stratification of Patients With Angina Due to Coronary Microvascular Dysfunction

Rahman, Haseeb; Demir, Ozan M.; Khan, Faisal; Ryan, M. J.; Ellis, Howard; Mills, Mark T; Chiribiri, Amedeo; Webb, David J.; Perera, Divaka

doi:10.1016/j.jacc.2020.03.051

Cited by 86 publications

(89 citation statements)

References 30 publications

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“…A recent study showed that HMR provides additional prognostic value to stratify patients’ risk to CFR by reflecting structural microvascular alteration such as capillary rarefaction, arteriolar obliteration, and perivascular fibrosis in addition to functional alteration. 7 , 8 Since RRR accounts for the pressure change while CFR does not, RRR in combination with HMR could better stratify the risk of all‐cause mortality than the combination of CFR and HMR in this study. Interestingly, both abnormal HMR and lower BMR were associated with lower survival in patients with abnormal RRR, providing additional prognostic values to RRR.…”

Section: Discussionmentioning

confidence: 88%

“…Abnormal CFR was defined as CFR <2.5. 8 , 15 BMR and HMR were calculated as the ratio of the mean aortic pressure (MAP) and the average peak velocity (APV) at baseline and hyperemia, respectively. Abnormal HMR was defined as HMR ≥2.0.…”

Section: Methodsmentioning

confidence: 99%

“…Recent studies suggested that endotypes of coronary microvascular dysfunction such as functional and structural could be differentiated using CFR and HMR. 7 , 8 Furthermore, HMR could provide an additional prognostic value over CFR in predicting MACEs. 9 There is currently lack of evidence whether stratification of patients with NOCAD using RRR and HMR could better stratify the risk of clinical outcomes than using CFR and HMR.…”

mentioning

confidence: 99%

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Risk Stratification of Patients With NonObstructive Coronary Artery Disease Using Resistive Reserve Ratio

Toya

Ahmad

Corban

et al. 2021

JAHA

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Background Resistive reserve ratio (RRR), or the ratio of baseline to hyperemic microvascular resistance, has prognostic implications in predicting clinical outcomes in patients with obstructive coronary artery disease. However, its value in patients with angina or ischemia with nonobstructive coronary artery disease is unknown. Methods and Results We included 1692 patients with nonobstructive coronary artery disease who underwent invasive coronary vasoreactivity testing. Abnormal coronary flow reserve (CFR, the ratio of hyperemic and baseline resting flow velocities) and RRR were defined as <2.5 and <2.62, respectively. The mortality rate was marginally higher in patients with abnormal CFR (428 patients [25%]) than those with normal CFR (38 [9%] versus 81 [6%]; P =0.08), and was significantly higher in patients with abnormal RRR (716 patients [42%]) than those with normal RRR (70 [10%] versus 49 [5%], P =0.0002) over the median follow‐up of 11.3 years. Patients with abnormal CFR had marginally lower survival than those with normal CFR (log‐rank P =0.08). In contrast, patients with abnormal RRR had significantly lower survival than those with normal RRR (log‐rank P =0.001). Abnormal RRR was associated with shorter time to death even after adjustment for other covariates (adjusted hazard ratio, 1.63; 95% CI, 1.11–2.38; P =0.01). Conclusions In patients with no obstructive coronary artery disease, RRR was superior to CFR in predicting long‐term survival. An RRR <2.62 was associated with 1.6 times increased risk of death in patients with nonobstructive coronary artery disease. Indices of coronary microcirculatory resistive reserve comprising flow‐ and pressure‐derived values may reflect underlying microvascular pathology more faithfully than flow‐alone indices like CFR.

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Section: Discussionmentioning

confidence: 88%

Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 99%

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Risk Stratification of Patients With NonObstructive Coronary Artery Disease Using Resistive Reserve Ratio

Toya

Ahmad

Corban

et al. 2021

JAHA

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“…Therefore, which treatment can reduce the cardiovascular event rate of CMVD is still unclear. Nevertheless, there have been small randomized clinical studies or non-randomized observational studies with CMVD as the research object and coronary microvascular function as the endpoint in the literature [79] , [80] . With the development of new drugs, we believe that more new drugs will be put into clinical use in the future.…”

Section: Pharmacotherapy Of Cmvdmentioning

confidence: 99%

Research progress on the molecular mechanism of coronary microvascular endothelial cell dysfunction

Deng¹

2021

IJC Heart & Vasculature

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Coronary microvascular disease is a high-risk factor for many cardiovascular events. However, due to its high concealment and many etiologies, the current understanding of its pathophysiological mechanism is very limited, which greatly limits its clinical diagnosis and treatment. In the process of the occurrence and development of coronary microvascular disease, the damage of coronary microvascular endothelial cell (CMEC) is the core link. CMEC's stress, metabolism, inflammation and other dysfunctions have a causal relationship with coronary microvascular disease, and are also the main features of coronary microvascular disease in the early stage. This article mainly reviews the molecular mechanisms of CMEC damage.

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“…The proportion of total resistance in epicardial arteries is negligible; small arteries account for 20% and arterioles are the largest accounting for 40% [5]. Functional and/or structural problems in the microcirculation underlie a susceptibility to myocardial ischemia and microvascular angina [5,10,11]. Microvascular dysfunction, reflected by impaired vasodilator capacity, remodeling, rarefaction or extrinsic factors, i.e.…”

Section: Microvascular Dysfunctionmentioning

confidence: 99%

What Is the Role of Assessing Ischemia to Optimize Therapy and Outcomes for Patients with Stable Angina and Non-obstructed Coronary Arteries?

Berry

Morrow

Marzilli

et al. 2021

Cardiovasc Drugs Ther

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Ischemic heart disease (IHD) is a leading global cause of ill-health and premature death. Clinical research into IHD is providing new insights into the pathophysiology, epidemiology and treatment of this condition. The major endotypes of IHD include coronary heart disease (CHD) and vasomotor disorders, including microvascular angina and vasospastic angina. Considering unselected patients presenting with stable chest pain, the pre-test probability of CHD is higher in men whereas the pre-test probability of a vasomotor disorder is higher in women. The diagnostic accuracy of diagnostic tests designed to assess coronary anatomy and disease and/or coronary vascular function (functional tests) differ for coronary endotypes. Clinical management should therefore be personalized and take account of sex-related factors. In this review, we consider the definitions of angina and myocardial ischemia. We then appraise the mechanistic links between myocardial ischemia and anginal symptoms and the relative merits of non-invasive and invasive diagnostic tests and related clinical management. Finally, we describe the rationale and importance of stratified medicine of IHD.

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Physiological Stratification of Patients With Angina Due to Coronary Microvascular Dysfunction

Cited by 86 publications

References 30 publications

Risk Stratification of Patients With NonObstructive Coronary Artery Disease Using Resistive Reserve Ratio

Risk Stratification of Patients With NonObstructive Coronary Artery Disease Using Resistive Reserve Ratio

Research progress on the molecular mechanism of coronary microvascular endothelial cell dysfunction

What Is the Role of Assessing Ischemia to Optimize Therapy and Outcomes for Patients with Stable Angina and Non-obstructed Coronary Arteries?

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