The significance of coronery reserve in clinical heart disease

Abstract

The clinical syndrome "coronary insufficiency with normal coronary arteriogram" is found in approximately 10% to 20% of patients with exercise-induced coronary insufficiency. In most of these cases, disturbances of the coronary microcirculation are present. They can appear in vascular diseases (arterial hypertension, systemic immunopathies, immune complex vasculitis), in rheologic diseases (paraproteinemia, hyperlipoproteinemia, polyglobulia) and in disturbances of transport and diffusion of oxygen (carbon monoxide intoxication, methemoglobinemia). The clinical diagnosis is based on the usual diagnostic procedures (electrocardiogram, exercise electrocardiogram, responsiveness to nitroglycerin), as well as on newer functionally oriented diagnostic procedures (determinations of coronary blood flow and coronary vascular reserve, production of lactate, serologic findings, histology and immune histology of peripheral arteries, measurements of viscosities in both plasma and blood). Many clinically relevant disturbances in the coronary microcirculation can thus be detected and treated on a rational basis by management of the underlying main disease, that is, by treatment of the vascular, rheologic and metabolic disorders. Persistent angina pectoris in the presence of a normal coronary arteriogram does not represent an end to coronary diagnostic procedures, but introduces the clinical task of using all diagnostic possibilities to enable functional and therapeutic assessment of the coronary microcirculation.

Carotid Intima-Media Thickness Is Correlated with Impairment of Coronary Flow Reserve in Hypertensive Patients without Coronary Artery Disease

“…Transient experimental coronary occlusion stimulates myocardial growth (19), and clinical studies have shown increased ventricular mass in patients with coronary stenosis (20). Several studies have reported that CFR was reduced in patients with hypertension, despite the absence of coronary stenosis (6)(7)(8)(9)(10)(11)(12)(13). This pathological alteration has been suggested to cause angina-like chest pain in hypertensive patients without coronary artery disease (21,22), and is regarded as a microvascular disturbance in hypertensive patients.…”

“…Following the initial hypothesis that this phenomenon in patients with hypertensive heart disease is caused by an inadequate blood supply due to impairment of coronary flow reserve (CFR), which is a sort of surrogate marker for coronary microcirculatory disturbance (6), numerous studies have supported the idea that hypertensive patients have reduced CFR (7)(8)(9)(10)(11)(12). However, the mechanisms of the impairment of CFR in hypertensive patients without coronary artery disease remain unclear.…”

Prevalence of Paroxysmal Atrial Fibrillation Depending on the Regression of Left Ventricular Hypertrophy in Arterial Hypertension

“…The pathophysiologic mechanism is based on diastolic and (later) systolic dysfunction of the left ventricle (21). Moreover, in patients with left ventricular hypertrophy, media hypertrophy of the arterioles is seen, resulting in an increased wall thickness-to-radius ratio (23,24). In consequence, coronary microangiopathy occurs.…”

“…In consequence, coronary microangiopathy occurs. Furthermore, the coronary flow reserve is reduced by up to 30% due to disturbances of the microcirculation (resistive vessels) and extravascular myocardial alterations (24)(25)(26). Additionally, interstitial fibrosis and an increased sympathetic tone can participate in the development of cardiac arrhythmias and particularly in the occurrence of atrial fibrillation (27,28).…”

Intracoronary Doppler– and Quantitative Coronary Angiography–Derived Predictors of Major Adverse Cardiac Events After Stent Implantation

“…19 -21 Especially in the presence of additional microvascular disease, [22][23][24] CVR after a successful stent implantation with minimization of the residual stenosis can remain low. This particular aspect may be neglected if CVR rel is applied.…”