Diagnosis of coronary microvascular dysfunction in the clinic

2020 ◽  
Vol 116 (4) ◽  
pp. 841-855 ◽  
Author(s):  
Peter Ong ◽  
Basmah Safdar ◽  
Andreas Seitz ◽  
Astrid Hubert ◽  
John F Beltrame ◽  
...  
Keyword(s):  
Coronary Flow ◽  
Coronary Thrombosis ◽  
Coronary Spasm ◽  
Microvascular Dysfunction ◽  
Coronary Microcirculation ◽  
Coronary Microvascular Dysfunction ◽  
Human Beings ◽  
Transthoracic Doppler Echocardiography ◽  
Non Invasive ◽  
Flow Reserve

Abstract The coronary microcirculation plays a pivotal role in the regulation of coronary blood flow and cardiac metabolism. It can adapt to acute and chronic pathologic conditions such as coronary thrombosis or long-standing hypertension. Due to the fact that the coronary microcirculation cannot be visualized in human beings in vivo, its assessment remains challenging. Thus, the clinical importance of the coronary microcirculation is still often underestimated or even neglected. Depending on the clinical condition of the respective patient, several non-invasive (e.g. transthoracic Doppler-echocardiography assessing coronary flow velocity reserve, cardiac magnetic resonance imaging, positron emission tomography) and invasive methods (e.g. assessment of coronary flow reserve (CFR) and microvascular resistance (MVR) using adenosine, microvascular coronary spasm with acetylcholine) have been established for the assessment of coronary microvascular function. Individual patient characteristics, but certainly also local availability, methodical expertise and costs will influence which methods are being used for the diagnostic work-up (non-invasive and/or invasive assessment) in a patient with recurrent symptoms and suspected coronary microvascular dysfunction. Recently, the combined invasive assessment of coronary vasoconstrictor as well as vasodilator abnormalities has been titled interventional diagnostic procedure (IDP). It involves intracoronary acetylcholine testing for the detection of coronary spasm as well as CFR and MVR assessment in response to adenosine using a dedicated wire. Currently, the IDP represents the most comprehensive coronary vasomotor assessment. Studies using the IDP to better characterize the endotypes observed will hopefully facilitate development of tailored and effective treatments.

Coronary Microcirculation in Heart Failure with Preserved Systolic Function

2018 ◽  
Vol 24 (25) ◽  
pp. 2960-2966
Author(s):  
Zorana Vasiljevic ◽  
Gordana Krljanac ◽  
Marija Zdravkovic ◽  
Ratko Lasica ◽  
Danijela Trifunovic ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Diastolic Dysfunction ◽  
Microvascular Dysfunction ◽  
Left Ventricular ◽  
Coronary Microcirculation ◽  
Left Ventricular Ejection ◽  
Coronary Microvascular Dysfunction ◽  
Fractional Flow ◽  
Flow Reserve

Background: The Heart Failure with Preserved Ejection Fraction (HFpEF) is defined as the preserved left ventricular ejection fraction (LVEF) with the signs of heart failure, elevated natriuretic peptides, and either the evidence of the structural heart disease or diastolic dysfunction. The importance of this form of heart failure was increased after studies where the mortality rates and readmission to the hospital were founded similar as in patients with HF and reduced EF (HFrEF). Coronary microvascular ischemia, cardiomyocyte injury and stiffness could be important factors in the pathophysiology of HFpEF. Methods: The goal of this work is to analyse the relationship of HFpEF and coronary microcirculation in previous studies. Results: The useful diagnostic marker of coronary microcirculation in HFpEF may be the parameters measured by transthoracic echocardiography (TTE), the coronary flow reserve (CFR), as well as fractional flow reserve (FFR) and quantitative myocardial contrast echocardiography (MCE). Cardiac magnetic resonance (CMR) imaging represents the diagnostic gold standard in HFpEF. Coronary microvascular dysfunction in the absence of obstructive coronary artery disease (CAD) is poorly understood and may be more prevalent amongst women than men. Troponin level may be important in risk stratification of HEpEF patients. Conclusion: There are no precise answers with respect to the pathophysiological mechanism, nor are there any precise practical clinical assessment of and diagnostic method for coronary microvascular dysfunction and diastolic dysfunction. In accordance with that, there is no well-established treatment for HFpEF.

scholarly journals Prevalence and correlates of coronary microvascular dysfunction in heart failure with preserved ejection fraction: PROMIS-HFpEF

2018 ◽  
Vol 39 (37) ◽  
pp. 3439-3450 ◽  
Author(s):  
Sanjiv J Shah ◽  
Carolyn S P Lam ◽  
Sara Svedlund ◽  
Antti Saraste ◽  
Camilla Hage ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Endothelial Dysfunction ◽  
Ejection Fraction ◽  
Microvascular Dysfunction ◽  
Left Ventricular ◽  
Coronary Microvascular Dysfunction ◽  
Preserved Ejection Fraction ◽  
Transthoracic Doppler Echocardiography ◽  
Flow Reserve

Abstract Aims To date, clinical evidence of microvascular dysfunction in patients with heart failure (HF) with preserved ejection fraction (HFpEF) has been limited. We aimed to investigate the prevalence of coronary microvascular dysfunction (CMD) and its association with systemic endothelial dysfunction, HF severity, and myocardial dysfunction in a well defined, multi-centre HFpEF population. Methods and results This prospective multinational multi-centre observational study enrolled patients fulfilling strict criteria for HFpEF according to current guidelines. Those with known unrevascularized macrovascular coronary artery disease (CAD) were excluded. Coronary flow reserve (CFR) was measured with adenosine stress transthoracic Doppler echocardiography. Systemic endothelial function [reactive hyperaemia index (RHI)] was measured by peripheral arterial tonometry. Among 202 patients with HFpEF, 151 [75% (95% confidence interval 69–81%)] had CMD (defined as CFR <2.5). Patients with CMD had a higher prevalence of current or prior smoking (70% vs. 43%; P = 0.0006) and atrial fibrillation (58% vs. 25%; P = 0.004) compared with those without CMD. Worse CFR was associated with higher urinary albumin-to-creatinine ratio (UACR) and NTproBNP, and lower RHI, tricuspid annular plane systolic excursion, and right ventricular (RV) free wall strain after adjustment for age, sex, body mass index, atrial fibrillation, diabetes, revascularized CAD, smoking, left ventricular mass, and study site (P < 0.05 for all associations). Conclusions PROMIS-HFpEF is the first prospective multi-centre, multinational study to demonstrate a high prevalence of CMD in HFpEF in the absence of unrevascularized macrovascular CAD, and to show its association with systemic endothelial dysfunction (RHI, UACR) as well as markers of HF severity (NTproBNP and RV dysfunction). Microvascular dysfunction may be a promising therapeutic target in HFpEF.

scholarly journals PSORIASIS EARLY IMPAIRS CORONARY FLOW RESERVE: NEW INSIGHTS INTO INFLAMMATION AND CORONARY MICROVASCULAR DYSFUNCTION

2010 ◽  
Vol 55 (10) ◽  
pp. A167.E1564
Author(s):  
Elena Osto ◽  
Stefano Piaserico ◽  
Anna Maddalozzo ◽  
Giulia Forchetti ◽  
Roberta Montisci ◽  
...  
Keyword(s):  
Coronary Flow Reserve ◽  
Coronary Flow ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Flow Reserve

scholarly journals Coronary Flow Velocity Reserve Assessment with Transthoracic Doppler Echocardiography

2015 ◽  
Vol 10 (1) ◽  
pp. 12 ◽  
Author(s):  
Iana Simova ◽  
Keyword(s):  
Flow Velocity ◽  
Doppler Echocardiography ◽  
Coronary Flow ◽  
Prognostic Significance ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Coronary Flow Velocity Reserve ◽  
Transthoracic Doppler Echocardiography ◽  
Coronary Flow Velocity ◽  
Atherosclerotic Burden

Coronary flow velocity reserve (CFVR) reflects global coronary atherosclerotic burden, endothelial function and state of the microvasculature. It could be measured using transthoracic Doppler echocardiography in a non-invasive, feasible, reliable and reproducible fashion, following a standardised protocol with different vasodilatory stimuli. CFVR measurement is a recommended complement to vasodilator stress echocardiography. It could serve as a diagnostic tool for coronary microvascular dysfunction and in the setting of epicardial coronary artery stenoses could help in identification and assessment of functional significance of coronary lesions and follow-up of patients after coronary interventions. CFVR has also a prognostic significance in different clinical situations.

scholarly journals Coronary Microvascular Dysfunction Restored After Surgery in Inflammatory Bowel Disease: A Prospective Observational Study

2021 ◽  
Author(s):  
Kentaro Kakuta ◽  
Kaoru Dohi ◽  
Takayuki Yamamoto ◽  
Naoki Fujimoto ◽  
Takahiro Shimoyama ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Flow Velocity ◽  
Crohn Disease ◽  
Coronary Flow ◽  
Linear Regression Analysis ◽  
Microvascular Dysfunction ◽  
Multiple Linear Regression Analysis ◽  
Coronary Microvascular Dysfunction ◽  
Transthoracic Doppler Echocardiography ◽  
Coronary Flow Velocity

Background We aimed to investigate the presence and severity of coronary microvascular dysfunction (CMD) in inflammatory bowel disease (IBD) including Crohn disease and ulcerative colitis and to elucidate the influence of surgical resection of the diseased intestines on CMD by assessing coronary flow velocity reserve (CFVR) using transthoracic Doppler echocardiography. Methods and Results Thirty‐seven patients with IBD (aged 44±15 years; 22 patients with Crohn disease and 15 patients with ulcerative colitis) and 30 controls (aged 46±12 years) were enrolled. For CFVR measurement, coronary flow velocity was recorded at rest and during hyperemia by ADP infusion using transthoracic Doppler echocardiography, and CFVR <2.5 defined CMD. CFVR measurement was repeated before and within 1 year after surgery. CFVR was similarly and significantly lower in patients with Crohn disease and those with ulcerative colitis than controls (Crohn disease: 2.92±1.03 [ P <0.05 versus controls], ulcerative colitis: 2.99±0.65 [ P <0.05 versus controls], and controls: 3.84±0.75). Multiple linear regression analysis showed that the presence of IBD and baseline hs‐CRP (high‐sensitivity C‐reactive protein) were independently associated with low CFVR among all study participants (β=−0.403 [ P =0.001] and −0.237 [ P =0.037], respectively). Hyperemic coronary flow velocity significantly improved after surgery only in patients with IBD who had CMD. CFVR significantly improved in patients with IBD who had both CMD and non‐CMD, and the extent of CFVR improvements were greater in patients with CMD than non‐CMD. Multiple linear regression analysis showed that the reduction of hs‐CRP was independently associated with improvement of hyperemic coronary flow velocity and CFVR among all patients with IBD (β=−0.481 [ P =0.003] and β=−0.334 [ P =0.043], respectively). Conclusions IBD is associated with CMD, which improved after surgical resection of diseased intestines.

P6220The non-invasive coronary flow reserve predicts exercise capacity in patients undergoing cardiac rehabilitation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
P Meimoun ◽  
M Ghannem ◽  
J Clerc
Keyword(s):  
Cardiac Rehabilitation ◽  
Exercise Capacity ◽  
Coronary Flow Reserve ◽  
Coronary Flow ◽  
Systolic Function ◽  
Left Ventricular ◽  
Maximal Heart Rate ◽  
Transthoracic Doppler Echocardiography ◽  
Non Invasive ◽  
Flow Reserve

Abstract Background The benefit of exercise on peripheral muscles is established but the exact role of the coronary microcirculation in exercise capacity after cardiac rehabilitation (CR) is unclear. Objective: Our aim was to test the relationship between non-invasive coronary flow reserve (CFR) and exercise capacity in patients undergoing CR after acute myocardial infarction (AMI). Methods CFR was performed by transthoracic Doppler echocardiography in the left anterior descending artery 24 h after angioplasty (CFR1) and after 20 sessions of CR program (at 4±1 months) (CFR2) in 60 consecutive patients (57±11 years, 30% women) with an anterior AMI successfully treated by primary coronary angioplasty. CFR was performed in a modified parasternal view using intravenous adenosine infusion (0.14 mg/kg/min within 2 minutes). CR program consisted of a half hour of fractioned exercise added of a half hour session of general gymnastics and body building. To test the exercise capacity, symptom limited exercise echocardiography was performed just after the CFR2, in a semi-supine position, starting at 25 watts, with 20–25 watts increments of workload every two minutes. Results CFR was measured successfully in all patients, and CFR2 was significantly higher than CFR1 (2.9±0.65 vs 1.9±0.4, p<0.001). Though CFR1 was correlated to left ventricular systolic function and its improvement at follow-up (all, p<0.01), CFR2 was independently related to exercise capacity (mean workload 100±30 watts, percent maximal heart rate 83±12%, no ischemia, no new wall motion abnormalities in all tests) after adjusting for age, sex, and body mass index (r=0.6, p<0.01). Conclusion CFR predicts exercise capacity in patients undergoing a CR program after AMI. The improvement of CFR contributes to cardiac performance.

scholarly journals Coronary microvascular function in athletes with abnormal exercise test results

2019 ◽  
Vol 27 (12) ◽  
pp. 621-628
Author(s):  
D. A. J. P. van de Sande ◽  
P. C. Barneveld ◽  
J. Hoogsteen ◽  
P. A. Doevendans ◽  
H. M. C. Kemps
Keyword(s):  
Coronary Flow Reserve ◽  
Myocardial Ischaemia ◽  
Coronary Flow ◽  
A Priori ◽  
Microvascular Dysfunction ◽  
Microvascular Function ◽  
Coronary Microvascular Dysfunction ◽  
Endothelin 1 ◽  
Flow Reserve ◽  
Coronary Microvascular Function

Abstract Aims In asymptomatic athletes, abnormal exercise test (ET) results have a poor positive predictive value. It is unknown whether abnormal ET results in the absence of obstructive coronary artery disease (CAD) are related to coronary microvascular dysfunction. It is also unknown whether they should be considered false-positive ET results or a consequence of physiological adaptation to sport. In our study, we evaluated whether athletes with abnormal ET results and documented myocardial ischaemia in the absence of obstructive CAD have an attenuated microvascular function and whether coronary microvascular dysfunction is related to endothelial dysfunction. Methods and results Nine athletes with concordant abnormal ET and myocardial perfusion scintigraphy (MPS) results without obstructive CAD were compared with age- and gender-matched individuals with a low-to-intermediate a priori risk of CAD. Coronary flow reserve was assessed by Rubidium-82 positron emission tomography (PET) imaging. Endothelin‑1 concentrations were measured to evaluate endothelial function. Coronary flow reserve was significantly lower in athletes (3.3 ± 0.8 versus 4.2 ± 0.6, p = 0.014 respectively). Endothelin‑1 levels were significantly higher in athletes (1.3 ± 0.2 pg/ml versus 1.0 ± 0.2 pg/ml, p = 0.012 respectively). There was no correlation between endothelin‑1 concentrations and mean global coronary flow reserve (r = 0.12). Conclusion Athletes with abnormal ET and MPS outcomes indicative for myocardial ischaemia and no obstructive CAD have a lower coronary flow reserve compared with non-athletes with low-to-intermediate a priori risk of CAD, suggesting an attenuated coronary microvascular function. Higher endothelin‑1 concentrations in athletes suggest that endothelial-dependent dysfunction is an important determinant of the attenuated microvascular function.

scholarly journals Angiogenic CD34 Stem Cell Therapy in Coronary Microvascular Repair—A Systematic Review

Cells ◽  
2021 ◽  
Vol 10 (5) ◽  
pp. 1137
Author(s):  
Balaj Rai ◽  
Janki Shukla ◽  
Timothy D. Henry ◽  
Odayme Quesada
Keyword(s):  
Quality Of Life ◽  
Cell Therapy ◽  
Coronary Flow Reserve ◽  
Coronary Flow ◽  
Controlled Trial ◽  
Microvascular Dysfunction ◽  
Treatment Modalities ◽  
Coronary Microvascular Dysfunction ◽  
Flow Reserve

Ischemia with non-obstructive coronary arteries (INOCA) is an increasingly recognized disease, with a prevalence of 3 to 4 million individuals, and is associated with a higher risk of morbidity, mortality, and a worse quality of life. Persistent angina in many patients with INOCA is due to coronary microvascular dysfunction (CMD), which can be difficult to diagnose and treat. A coronary flow reserve <2.5 is used to diagnose endothelial-independent CMD. Antianginal treatments are often ineffective in endothelial-independent CMD and thus novel treatment modalities are currently being studied for safety and efficacy. CD34+ cell therapy is a promising treatment option for these patients, as it has been shown to promote vascular repair and enhance angiogenesis in the microvasculature. The resulting restoration of the microcirculation improves myocardial tissue perfusion, resulting in the recovery of coronary microvascular function, as evidenced by an improvement in coronary flow reserve. A pilot study in INOCA patients with endothelial-independent CMD and persistent angina, treated with autologous intracoronary CD34+ stem cells, demonstrated a significant improvement in coronary flow reserve, angina frequency, Canadian Cardiovascular Society class, and quality of life (ESCaPE-CMD, NCT03508609). This work is being further evaluated in the ongoing FREEDOM (NCT04614467) placebo-controlled trial.

Sign in / Sign up

Export Citation Format

Share Document