scholarly journals Diagnostic Approach to Patients with Stable Angina and No Obstructive Coronary Arteries

2019 ◽  
Vol 14 (2) ◽  
pp. 97-102 ◽  
Author(s):  
Gaetano Antonio Lanza
Keyword(s):  
Coronary Arteries ◽  
Microvascular Dysfunction ◽  
Definitive Diagnosis ◽  
Diagnostic Approach ◽  
Coronary Microvascular Dysfunction ◽  
Stress Tests ◽  
Transthoracic Doppler Echocardiography ◽  
Microvascular Angina ◽  
Non Invasive ◽  
Intracoronary Doppler

The diagnosis of microvascular angina (MVA) is usually considered in patients presenting with angina symptoms and evidence of MI on non-invasive stress tests but normal coronary arteries at angiography. A definitive diagnosis of MVA, however, would require the presence of coronary microvascular dysfunction. Several invasive (e.g. intracoronary Doppler wire recording and thermodilution) and non-invasive (e.g. PET, cardiac MRI, transthoracic Doppler echocardiography) methods can be applied to obtain a diagnosis. Both endothelium- dependent and -independent coronary microvascular dilator function, as well as increased microvascular constrictor activity, should be investigated. The main issues in the assessment of clinical and diagnostic findings in patients with suspected MVA are discussed and a diagnostic approach is suggested.

scholarly journals Clinico-pathophysiological considerations in coronary microvascular disorders

Vessel Plus ◽  
2022 ◽  
Author(s):  
Sarena La ◽  
Rosanna Tavella ◽  
Sivabaskari Pasupathy ◽  
John F. Beltrame
Keyword(s):  
Coronary Arteries ◽  
Myocardial Ischaemia ◽  
Pain Perception ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Microvascular Angina ◽  
Common Clinical Presentation ◽  
Microvascular Spasm ◽  
Underlying Mechanisms ◽  
Microvascular Resistance

Around half of the patients undergoing an elective coronary angiogram to investigate typical stable angina symptoms are found to have non-obstructive coronary arteries (defined as < 50% stenosis). These patients are younger with a female predilection. While underlying mechanisms responsible for these presentations are heterogeneous, structural and functional abnormalities of the coronary microvasculature are highly prevalent. Thus, coronary microvascular dysfunction (CMD) is increasingly recognised as an important consideration in patients with non-obstructive coronary arteries. This review will focus on primary coronary microvascular disorders and summarise the four common clinical presentation pictures which can be considered as endotypes - Microvascular Ischaemia (formerly “Syndrome X”), Microvascular Angina, Microvascular Spasm, and Coronary Slow Flow. Furthermore, the pathophysiological mechanisms associated with CMD are also heterogenous. CMD may arise from an increased microvascular resistance, impaired microvascular dilation, and/or inducible microvascular spasm, ultimately causing myocardial ischaemia and angina. Alternatively, chest pain may arise from hypersensitivity of myocardial pain receptors rather than myocardial ischaemia. These two major abnormalities should be considered when assessing an individual clinical picture, and ultimately, the question arises whether to target the heart or the pain perception to treat the anginal symptoms.

scholarly journals Takotsubo Cardiomyopathy: One More Angiographic Evidence of Microvascular Dysfunction

2018 ◽  
Vol 2018 ◽  
pp. 1-6 ◽  
Author(s):  
Marco Loffi ◽  
Andrea Santangelo ◽  
Martin Kozel ◽  
Viktor Kocka ◽  
Tomas Budesinsky ◽  
...  
Keyword(s):  
Myocardial Perfusion ◽  
Coronary Arteries ◽  
Takotsubo Cardiomyopathy ◽  
Coronary Flow ◽  
Microvascular Dysfunction ◽  
Control Group ◽  
Coronary Microvascular Dysfunction ◽  
Microvascular Angina ◽  
Timi Frame Count ◽  
Angiographic Evidence

Background. Takotsubo cardiomyopathy (TC) aetiology has not been completely understood yet. One proposed pathogenic mechanism was coronary microvascular dysfunction (MVD). This study compared coronary flow and myocardial perfusion in patients with TC, microvascular angina (MVA), and a control group (CG). Methods. Out of 42 consecutive patients presented to our centre with TC from 2013 to 2017; we retrospectively selected 27 patients. We compared them with a sex- and age-matched group of 27 MVA cases and 27 patients with normal coronary arteries (CG). The flow was evaluated in the three coronary arteries as TIMI flow and TIMI frame count (TFC). Myocardial perfusion was studied with Blush-Score and Quantitative Blush Evaluator (QuBE). Results. TFC, in TC, revealed flow impairment in the three arteries compared to the CG (left anterior descending artery (LAD): 22±8, 15±4; p=0.001) (right coronary artery: 12±4, 10±3; p=0,025) (left circumflex: 14±4, CG 11±3; p=0,006). QuBE showed myocardial perfusion impairment in the LAD territory in TC comparing with both the CG (8,9 (7,2–11,5) versus 11,4 (10–15,7); p=0,008) and the MVA group (8,9 (7,2–11,5) versus 13,5 (10–16); p=0,006). Conclusions. Our study confirmed that coronary flow is impaired in TC, reflecting a MVD. Myocardial perfusion defect was detected only in the LAD area.

scholarly journals ‘Primary’ Microvascular Angina: Clinical Characteristics, Pathogenesis and Management

2018 ◽  
Vol 13 (3) ◽  
pp. 108 ◽  
Author(s):  
Gaetano Antonio Lanza ◽  
Antonio De Vita ◽  
Juan-Carlos Kaski ◽  
◽  
◽  
...  
Keyword(s):  
Clinical Practice ◽  
Clinical Characteristics ◽  
Microvascular Dysfunction ◽  
Coronary Microcirculation ◽  
Diagnostic Tools ◽  
Coronary Microvascular Dysfunction ◽  
Pharmacological Treatments ◽  
Microvascular Angina ◽  
Non Invasive ◽  
Prognostic Implications

Microvascular angina (MVA), i.e. angina caused by abnormalities of the coronary microcirculation, is increasingly recognised in clinical practice. The pathogenetic mechanisms of MVA are heterogeneous and may involve both structural and functional alterations of coronary microcirculation, and functional abnormalities may variably involve an impairment of coronary microvascular dilatation and an increased microvascular constrictor activity. Both invasive and non-invasive diagnostic tools exist to identify patients with MVA in clinical practice. Prognosis has been reported to be good in primary MVA patients, although the prognostic implications of coronary microvascular dysfunction (CMVD) in more heterogeneous populations of angina patients need further assessment. Management of primary MVA can be challenging, but pharmacological and non-pharmacological treatments exist that allow satisfactory control of symptoms in most patients

The many faces of myocardial ischaemia and angina

2019 ◽  
Vol 115 (10) ◽  
pp. 1460-1470 ◽  
Author(s):  
Bernard I Levy ◽  
Gerd Heusch ◽  
Paolo G Camici
Keyword(s):  
Blood Flow ◽  
Coronary Arteries ◽  
Myocardial Ischaemia ◽  
Obstructive Coronary Artery Disease ◽  
Coronary Spasm ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Microvascular Angina ◽  
Number Of Patients ◽  
Metabolic Vasodilation

Abstract Obstructive disease of the epicardial coronary arteries is the main cause of angina. However, a number of patients with anginal symptoms have normal coronaries or non-obstructive coronary artery disease (CAD) despite electrocardiographic evidence of ischaemia during stress testing. In addition to limited microvascular vasodilator capacity, the coronary microcirculation of these patients is particularly sensitive to vasoconstrictor stimuli, in a condition known as microvascular angina. This review briefly summarizes the determinants and control of coronary blood flow (CBF) and myocardial perfusion. It subsequently analyses the mechanisms responsible for transient myocardial ischaemia: obstructive CAD, coronary spasm and coronary microvascular dysfunction in the absence of epicardial coronary lesions, and variable combinations of structural anomalies, impaired endothelium-dependent and/or -independent vasodilation, and enhanced perception of pain. Lastly, we exemplify mechanism of angina during tachycardia. Distal to a coronary stenosis, coronary dilator reserve is already recruited and can be nearly exhausted at rest distal to a severe stenosis. Increased heart rate reduces the duration of diastole and thus CBF when metabolic vasodilation is no longer able to increase CBF. The increase in myocardial oxygen consumption and resulting metabolic vasodilation in adjacent myocardium without stenotic coronary arteries further acts to divert blood flow away from the post-stenotic coronary vascular bed through collaterals.

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.

PET-CT and detection of coronary artery disease

2021 ◽  
pp. 421-434
Author(s):  
Marcelo F. Di Carli
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Microvascular Dysfunction ◽  
Quantitative Information ◽  
Left Ventricular ◽  
Coronary Microvascular Dysfunction ◽  
Non Invasive ◽  
Atherosclerotic Burden ◽  
Pet Ct ◽  
Artery Disease

Myocardial perfusion PET/CT imaging has emerged as a powerful and comprehensive non-invasive approach for the management of patients with suspected or known coronary artery disease (CAD). The multiparametric PET/CT approach provides quantitative information about the extent and severity of focal and diffuse CAD, coronary microvascular dysfunction (CMD), atherosclerotic burden, and left ventricular function. Contemporary evidence demonstrates that this comprehensive approach is one of the most accurate non-invasive tools for diagnosis, risk prediction, and guiding management in patients with CAD. This chapter summarizes the versatility of the integrated PET/CT scan to provide detailed quantitative information tailored to the patient and clinical question. I then review patient-centred clinical applications using case vignettes to illustrate indications of PET/CT and how to present the findings into clinically actionable information for the practising cardiologist. In each case, I review the available data highlighting the diagnostic and prognostic value of the integrated PET/CT protocol.

scholarly journals Coronary Microvascular Dysfunction: An Update

2020 ◽  
Vol 16 (1) ◽  
pp. 43-49
Author(s):  
Sm Mustafa Zaman ◽  
Harisul Hoque ◽  
Khurshed Ahmed ◽  
Md Mukhlesur Rahman ◽  
Msi Tipu Chowdhury ◽  
...  
Keyword(s):  
Magnetic Resonance ◽  
Myocardial Perfusion ◽  
Current Knowledge ◽  
Systolic Dysfunction ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Resonance Spectroscopy ◽  
Channel Blockers ◽  
Converting Enzyme Inhibitors ◽  
Microvascular Angina

Structural and functional abnormalities of the microcirculation can impair myocardial perfusion which is called coronary microvascular dysfunction and the resulting ischemia is known as microvascular ischaemia. Most of the researches have focused on the epicardial coronary arteries while addressing angina pectoris. Although the importance of the coronary microcirculation in maintaining appropriate myocardial perfusion has been recognized for several decades, the substantial morbidity of coronary microvascular dysfunction (CMD) has not been appreciated until recently. It is not possible to diagnose of microvascular angina clinically with the current knowledge. Resting or exercise electrocardiogram is nondiagnostic. Imaging with speckle tracking in echocardiography may reveal focal diastolic and/or systolic dysfunction. Other noninvasive investigations includes, Contrast stress echocardiography, 99Tc-sestamibi imaging, cardiovascular magnetic resonance (CMR),Nuclear magnetic resonance spectroscopy may show some degree of abnormality. Invasive methods like intracoronary adenosine and acetylecholine test may guide us to diagnose CMD. No guideline directed medical therapy is still available for the CMD. Risk factors modification like smoking cessation and weight-loss may improve endothelial dysfunction and CMD. Beta blockers, calcium channel blockers, Angiotensin converting enzyme inhibitors and statin are now used in different clinical condition related to microvascular angina. After these medical treatment patient with microvascular angina have higher risk of MACE compared with people without angina. So, physicians must be aware of this potentially fatal but under recognized clinical entity. University Heart Journal Vol. 16, No. 1, Jan 2020; 43-49

scholarly journals Non-invasive assessment of microvascular dysfunction in patients with microvascular angina

2017 ◽  
Vol 248 ◽  
pp. 433-439 ◽  
Author(s):  
Caroline Jaarsma ◽  
Hans Vink ◽  
Judith van Haare ◽  
Sebastiaan C.A.M. Bekkers ◽  
Bart D. van Rooijen ◽  
...  
Keyword(s):  
Microvascular Dysfunction ◽  
Microvascular Angina ◽  
Non Invasive

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 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.

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