Targeting the dominant mechanism of coronary microvascular dysfunction with intracoronary physiology tests

Mejía‐Rentería, Hernán; Hoeven, Nina van der; Hoef, Tim P. van de; Heemelaar, Julius C.; Ryan, Nicola; Lerman, Amir; Royen, Niels van; Escaned, Javier

doi:10.1007/s10554-017-1136-9

Cited by 57 publications

(42 citation statements)

References 122 publications

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“…A comprehensive assessment of microvascular function includes testing the two main mechanisms of microvascular dysfunction: (a) impaired endothelium-independent microvascular vasodilatation, which is measured by coronary flow reserve (CFR) and by index of microvascular resistance (IMR), and (b) impaired endothelium-dependent dysfunction, which evaluates the induction of epicardial or microvascular spasm after intracoronary injection of acetylcholine [ 3 , 29 , 254 , 262 , 263 ]. In addition, coronary microcirculation may be also adversely affected by embolization of thrombotic material following percutaneous coronary intervention.…”

Section: Diagnosis Of Cmdmentioning

confidence: 99%

Coronary Microvascular Dysfunction

Vancheri¹,

Longo²,

Vancheri

et al. 2020

JCM

202

153

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Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed “ischemia with non-obstructive coronary artery disease” (INOCA) and for a small proportion of “myocardial infarction with non-obstructive coronary artery disease” (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).

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Section: Diagnosis Of Cmdmentioning

confidence: 99%

Coronary Microvascular Dysfunction

Vancheri¹,

Longo²,

Vancheri

et al. 2020

JCM

202

153

View full text Add to dashboard Cite

show abstract

“…In July 2017 the Topical issue on Emerging concepts on Invasive and Noninvasive Coronary Physiological Assessment was published with a great overview over the various imaging modalities with a total of 15 scientific papers by the experts in this field on invasive and non-invasive flow reserve, flow-pressure relationships, microvascular dysfunction, perfusion imaging and wall shear stress [94][95][96][97][98][99][100][101][102][103][104][105][106][107][108].…”

Section: Topical Issue On Emerging Concepts On Invasive and Noninvasimentioning

confidence: 99%

Cardiovascular imaging 2017 in the International Journal of Cardiovascular Imaging

Reiber

Alaiti

Bezerra

et al. 2018

Int J Cardiovasc Imaging

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“…Virtual FFR derived from computed tomography or angiography is a promising tool to predict FFR based on the assumption of preserved flow reserve and myocardial mass. In patients with microvascular impairment such as diabetes, a high index of microvascular resistance or post myocardial infarction diagnosis accuracy might be lower; therefore, test results should be taken with cautions ( 49 , 50 ).…”

Section: Introductionmentioning

confidence: 99%

Coronary artery disease evaluation by coronary angiography and intracoronary imaging compared to Fractional Flow Reserve: anatomical-functional mismatch.

Adjedj¹

2018

Anatol J Cardiol

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Myocardial ischemia is a leading cause of death worldwide, and it corresponds to the imbalance between blood supply and myocardial demand. Epicardial coronary artery disease (CAD) is detected on the basis of coronary angiogram, whereas invasive detection of myocardial ischemia induced by coronary stenosis is commonly based on fractional flow reserve (FFR). The use of FFR for revascularization decision-making demonstrated clinical benefit and cost-effectiveness compared with that of angiographic indices. Discrepancies between anatomical metrics and physiological assessment of CAD are frequent, which lead to change in revascularization decision from angiography compared to functional evaluation of CAD. Despite several clinical studies and guidelines recommending with high level of evidence demonstrating that FFR should be adopted in stable CAD, revascularization decision-making is still based on coronary angiogram in current practice. Because of the unique coronary anatomy, coronary stenosis characteristics, risk factors profile, and microcirculation quality, the unique evaluation based on epicardial coronary stenosis threshold failed to be a landmark of ischemia compared with FFR. Furthermore, coronary angiogram can detect only epicardial vessels, which represent only 10% of the entire coronary vasculature; therefore, microcirculation is not seen and is poorly assessed in clinical practice. Thus, the role of microcirculation is of importance in myocardial ischemia and might impact these discrepancies between angiography and FFR evaluation of CAD. In this review, we aimed to describe the poor correlation between anatomical evaluation compared with physiological evaluation to detect myocardial ischemia induced by coronary stenosis as well as the clinical implications of this visual–functional mismatch.

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Targeting the dominant mechanism of coronary microvascular dysfunction with intracoronary physiology tests

Cited by 57 publications

References 122 publications

Coronary Microvascular Dysfunction

Coronary Microvascular Dysfunction

Cardiovascular imaging 2017 in the International Journal of Cardiovascular Imaging

Coronary artery disease evaluation by coronary angiography and intracoronary imaging compared to Fractional Flow Reserve: anatomical-functional mismatch.

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