Microvascular coronary dysfunction and ischemic heart disease: where are we in 2014?

Abstract

Many patients with angina and signs of myocardial ischemia on stress testing have no significant obstructive epicardial coronary disease. There are many potential coronary and non-coronary mechanisms for ischemia without obstructive epicardial coronary disease, and prominent among these is coronary microvascular and/or endothelial dysfunction. Patients with coronary microvascular and/or endothelial dysfunction are often at increased risk of adverse cardiovascular events, including ischemic events and heart failure despite preserved ventricular systolic function. In this article, we will review the diagnosis and treatment of coronary microvascular and endothelial dysfunction, discuss their potential contribution to heart failure with preserved ejection fraction, and highlight recent advances in the evaluation of atherosclerotic morphology in these patients, many of whom have non-obstructive epicardial disease.

Figure 1

Survival free of death, myocardial infarction, stroke, or heart failure hospitalization in those patients with a coronary flow reserve above or below a receiver operating curve–determined optimal cut-off value of 2.32. Reprinted with permission from Pepine et al. J Am Coll Cardiol. 2010;55:2825–2832.

Figure 1

Survival free of death, myocardial infarction, stroke, or heart failure hospitalization in those patients with a coronary flow reserve above or below a receiver operating curve–determined optimal cut-off value of 2.32. Reprinted with permission from Pepine et al. J Am Coll Cardiol. 2010;55:2825–2832.

Figure 2

TIMI Frame Count: The first frame used to determine the TIMI Frame Count is the frame in which dye fully enters the artery of interest (left, arrow). The last frame that is counted is the frame when dye enters the distal landmark branch (right, arrow). Reprinted with permission from Petersen et al. PLoS One. 2014;9:e96630.

Figure 3

Patient with normal lumen area on right coronary angiography (left) but significant plaque of the right coronary artery seen on intravascular ultrasound (right).