Myocardial ischaemia: definition and causes

ESC CardioMed ◽  
2018 ◽  
pp. 1325-1329
Author(s):  
Filippo Crea ◽  
Gaetano Antonio Lanza
Keyword(s):  
Coronary Artery ◽  
Myocardial Ischaemia ◽  
Coronary Artery Spasm ◽  
Chronic Stable Angina ◽  
Oxygen Demand ◽  
Microvascular Dysfunction ◽  
Myocardial Oxygen Demand ◽  
Coronary Microvascular Dysfunction ◽  
Coronary Artery Dissection ◽  
The Right

Myocardial ischaemia is caused by a mismatch between myocardial oxygen demand and myocardial blood flow supply, which results in reversible myocardial suffering and, when prolonged, in irreversible injury. The main causes of myocardial ischaemia include (1) atherosclerotic flow-limiting stenoses which are responsible for chronic stable angina; (2) coronary thrombus superimposed on an atherosclerotic plaque which is responsible for acute coronary syndromes; (3) coronary artery spasm which is responsible for vasospastic angina; and (4) coronary microvascular dysfunction which is responsible for microvascular angina and can also contribute to myocardial ischaemia in various clinical settings. Functional alterations (thrombus, spasm, and microvascular dysfunction) may act on angiographically normal coronary arteries or arteries presenting stenoses of variable severity. Less frequent coronary causes of myocardial ischaemia include spontaneous coronary artery dissection, myocardial bridge, coronary thromboembolism, an abnormal origin of the right or left coronary artery, and ascending aorta dissection involving coronary ostia. Finally, myocardial ischaemia can occur in the presence of severe left ventricular hypertrophy as observed in aortic stenosis and hypertrophic cardiomyopathy.

Myocardial ischaemia: definition and causes

ESC CardioMed ◽  
2018 ◽  
pp. 1325-1329
Author(s):  
Filippo Crea ◽  
Gaetano Antonio Lanza
Keyword(s):  
Blood Flow ◽  
Coronary Artery ◽  
Myocardial Ischaemia ◽  
Coronary Artery Spasm ◽  
Coronary Vessels ◽  
Oxygen Demand ◽  
Myocardial Oxygen Demand ◽  
Clinical Settings ◽  
Variant Angina ◽  
Coronary Microvascular Function

Myocardial ischaemia is caused by a mismatch between myocardial oxygen demand and myocardial blood flow supply, which results in myocardial suffering and, when prolonged, injury. The main mechanisms of myocardial ischaemia include atherothrombotic lesions of epicardial coronary vessels, which may result in chronic and acute ischaemic syndromes; coronary artery spasm, which is mainly responsible for variant angina; and abnormalities in coronary microvascular function, which can cause or contribute to myocardial ischaemia in various clinical settings.

scholarly journals Coronary Flow Reserve in Patients With Prior Spontaneous Coronary Artery Dissection and Recurrent Angina

2020 ◽  
Vol 9 (16) ◽  
Author(s):  
Tara Sedlak ◽  
Andrew Starovoytov ◽  
Karin Humphries ◽  
Jacqueline Saw
Keyword(s):  
Chest Pain ◽  
Coronary Artery ◽  
Coronary Flow ◽  
Fibromuscular Dysplasia ◽  
Microvascular Dysfunction ◽  
Artery Dissection ◽  
Coronary Microvascular Dysfunction ◽  
Coronary Artery Dissection ◽  
Flow Reserve ◽  
Index Of Microcirculatory Resistance

Background A significant proportion of patients with spontaneous coronary artery dissection (SCAD) have ongoing chronic chest pain despite healing of their dissection. We sought to determine whether coronary microvascular dysfunction contributes to post‐SCAD chronic chest pain by performing coronary reactivity testing in the cardiac catheterization laboratory. Methods and Results Eighteen patients consented to coronary reactivity testing at least 3 months post‐SCAD. Coronary flow reserve (CFR) and index of microcirculatory resistance were measured in the previously affected SCAD artery and 1 non‐SCAD artery. CFR <2.5 was defined as diagnostic of coronary microvascular dysfunction. An abnormal index of microcirculatory resistance was defined as >25 units. Seventeen women underwent coronary reactivity testing (1 had chronic dissection and was excluded). All presented with myocardial infarction and 2 underwent coronary stenting during the initial SCAD event. Fibromuscular dysplasia was present in 70.6% upon screening renal, iliac, and cerebrovascular arteries. Twelve patients (70.6%) had CFR <2.5 and 13 (76.5%) had an index of microcirculatory resistance >25 in at least 1 artery. There was no difference in the frequency of a low CFR measurement between SCAD and non‐SCAD arteries. Conclusions Among patients with chronic chest pain after an SCAD event, >70% had coronary microvascular dysfunction as indicated by abnormal CFR or index of microcirculatory resistance in at least 1 coronary artery on invasive coronary reactivity testing. Presence of coronary microvascular dysfunction in both SCAD and non‐SCAD arteries suggests that underlying microvascular abnormalities from vasculopathies such as coronary fibromuscular dysplasia may be the underlying etiology.

scholarly journals Coronary Microvascular Dysfunction and the Role of Noninvasive Cardiovascular Imaging

Diagnostics ◽  
2020 ◽  
Vol 10 (9) ◽  
pp. 679
Author(s):  
Muhammad Talha Ayub ◽  
Dinesh Kalra
Keyword(s):  
Imaging Techniques ◽  
Oxygen Demand ◽  
Microvascular Dysfunction ◽  
Cardiac Imaging Techniques ◽  
Myocardial Oxygen Demand ◽  
Coronary Microvascular Dysfunction ◽  
Non Invasive ◽  
Treatment Prognosis

Patients with coronary microvascular dysfunction (CMD) have significantly higher rates of cardiovascular events, including hospitalization for heart failure, sudden cardiac death, and myocardial infarction (MI). In CMD, several pathophysiological changes lead to functional and structural abnormalities in the coronary microvasculature, which disrupt the ability of the vessels to vasodilate and augment myocardial blood flow in response to increased myocardial oxygen demand, causing ischemia and angina. With the advent of more advanced non-invasive cardiac imaging techniques, the coronary microvasculature has been subjected to more intense study in the past two decades—this has led to further insights into the diagnosis, pathophysiology, treatment, prognosis and follow-up of CMD. This review will highlight and compare the salient features of the currently available non-invasive imaging modalities used in these patients, and discuss the clinical utility of these techniques in the workup and management of these patients.

scholarly journals ESC Working Group on Coronary Pathophysiology and Microcirculation position paper on ‘coronary microvascular dysfunction in cardiovascular disease’

2020 ◽  
Vol 116 (4) ◽  
pp. 741-755 ◽  
Author(s):  
Teresa Padro ◽  
Olivia Manfrini ◽  
Raffaele Bugiardini ◽  
John Canty ◽  
Edina Cenko ◽  
...  
Keyword(s):  
Cardiovascular Risk ◽  
Coronary Artery ◽  
Myocardial Ischaemia ◽  
Current Knowledge ◽  
Clinical Importance ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Epicardial Coronary Artery ◽  
Clinical Consequences ◽  
Artery Disease

  Although myocardial ischaemia usually manifests as a consequence of atherosclerosis-dependent obstructive epicardial coronary artery disease, a significant percentage of patients suffer ischaemic events in the absence of epicardial coronary artery obstruction. Experimental and clinical evidence highlight the abnormalities of the coronary microcirculation as a main cause of myocardial ischaemia in patients with ‘normal or near normal’ coronary arteries on angiography. Coronary microvascular disturbances have been associated with early stages of atherosclerosis even prior to any angiographic evidence of epicardial coronary stenosis, as well as to other cardiac pathologies such as myocardial hypertrophy and heart failure. The main objectives of the manuscript are (i) to provide updated evidence in our current understanding of the pathophysiological consequences of microvascular dysfunction in the heart; (ii) to report on the current knowledge on the relevance of cardiovascular risk factors and comorbid conditions for microcirculatory dysfunction; and (iii) to evidence the relevance of the clinical consequences of microvascular dysfunction. Highlighting the clinical importance of coronary microvascular dysfunction will open the field for research and the development of novel strategies for intervention will encourage early detection of subclinical disease and will help in the stratification of cardiovascular risk in agreement with the new concept of precision medicine.

scholarly journals The Role of Mental Stress in Ischaemia with No Obstructive Coronary Artery Disease and Coronary Vasomotor Disorders

2021 ◽  
Vol 16 ◽  
Author(s):  
Roos ET van der Meer ◽  
Angela HEM Maas
Keyword(s):  
Coronary Artery Disease ◽  
Heart Disease ◽  
Coronary Artery ◽  
Psychological Stress ◽  
Myocardial Ischaemia ◽  
Mental Stress ◽  
Obstructive Coronary Artery Disease ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Artery Disease

Ischaemic heart disease has been estimated to affect 126.5 million people globally. Approximately 70% of patients with angina and suspected myocardial ischaemia show no signs of obstructed coronary arteries after coronary angiography, but may still demonstrate ischaemia. Ischaemia with no obstructive coronary artery disease (INOCA) is increasingly acknowledged as a serious condition because of its association with poor quality of life and elevated risk for cardiovascular events. The negative effects of psychological stress on INOCA are gaining more attention. Psychological stress is associated with adverse cardiovascular outcomes such as mental stress-induced myocardial ischaemia. Psychological stress includes anxiety, depression, anger and personality disturbances. Coronary microvascular dysfunction and coronary arterial spasm are phenotypes of coronary vasomotor disorders that are triggered by psychological distress and depression, thereby increasing cardiovascular disease risk. Coronary vasomotor disorders are often co-existent in INOCA patients and might be considered as a contributing factor to mental stress-associated adverse cardiovascular outcomes. Additionally, psychological stress induces endothelial dysfunction more often in (young) women with INOCA than in men. Overall, many studies demonstrate an association between mental stress, coronary microvascular dysfunction and coronary vasospasm in patients with INOCA – especially women. Future research on stress-reducing therapies that target coronary vasomotor disorders in patients with INOCA is needed. This is particularly the case in young adolescents, in whom this type of ischaemic heart disease is increasing.

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