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.

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.

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 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.

Imaging of microvascular disease

2021 ◽  
pp. 481-494
Author(s):  
Paolo G. Camici ◽  
Ornella Rimoldi
Keyword(s):  
Myocardial Ischaemia ◽  
Imaging Techniques ◽  
Microvascular Disease ◽  
Microvascular Dysfunction ◽  
Microvascular Function ◽  
Coronary Microvascular Dysfunction ◽  
Maximal Increase ◽  
Asymptomatic Subjects ◽  
Coronary Microvascular Function

Beside obstructive disease of the epicardial coronary arteries dysfunction of the coronary microvasculature has emerged in the past 20 years as an additional mechanism of myocardial ischaemia. The coronary microvasculature cannot be directly visualized in vivo, therefore, both invasive and non-invasive techniques, have been developed to assess parameters that depend directly on coronary microvascular function. Studies at the microcirculatory level entail the use of vasodilators to obtain near-maximal vasodilation. The ratio of the maximal increase of blood flow above its resting value the coronary flow reserve (CFR) allows to gain an insight into the integrated circulatory function. The diagnostic accuracy of imaging techniques can be exploited to detect impairments of myocardial perfusion in asymptomatic subjects with cardiovascular risk factors. The assessment of the coronary microvascular function has provided novel details on the pathophysiological role of coronary microvascular dysfunction in the development of myocardial ischaemia bearing also important prognostic implications.

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

Clinical, angiographic and echocardiographic correlates of epicardial and microvascular spasm in patients with myocardial ischaemia and non-obstructive coronary arteries

2019 ◽  
Vol 109 (4) ◽  
pp. 435-443 ◽  
Author(s):  
Rocco Antonio Montone ◽  
Giampaolo Niccoli ◽  
Michele Russo ◽  
Marta Giaccari ◽  
Marco Giuseppe Del Buono ◽  
...  
Keyword(s):  
Coronary Arteries ◽  
Myocardial Ischaemia ◽  
Microvascular Spasm

Invasive assessment of coronary microvascular dysfunction in hypertrophic cardiomyopathy: the index of microvascular resistance

2015 ◽  
Vol 16 (7) ◽  
pp. 426-428 ◽  
Author(s):  
Alejandro Gutiérrez-Barrios ◽  
Francisco Camacho-Jurado ◽  
Enrique Díaz-Retamino ◽  
Sergio Gamaza-Chulián ◽  
Antonio Agarrado-Luna ◽  
...  
Keyword(s):  
Hypertrophic Cardiomyopathy ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Index Of Microvascular Resistance ◽  
Microvascular Resistance

The coronary microcirculation and coronary microvascular dysfunction

2021 ◽  
pp. 18-21
Author(s):  
Romana Herscovici ◽  
C. Noel Bairey Merz
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Obstructive Coronary Artery Disease ◽  
Signs And Symptoms ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Microvascular Angina ◽  
Cardiac Syndrome ◽  
Artery Disease

The role of revascularization in the treatment of obstructive coronary artery disease is well established, and its impact on improving survival has been proven. Nevertheless, patients with signs and symptoms considered of cardiac origin but with no obstructive coronary artery disease on coronary angiography are increasingly seen. Initially described as a ‘paradox’ or cardiac syndrome X and subsequently defined as microvascular angina, angina-like chest pain and evidence of ischaemia with non-obstructive coronary artery disease, is the consequence of altered coronary microvascular response to various stimuli despite non-obstructed epicardial vessels.

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