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Targeting the dominant mechanism of coronary microvascular dysfunction with intracoronary physiology tests

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Abstract

The coronary microcirculation plays a key role in modulating blood supply to the myocardium. Several factors like myocardial oxygen demands, endothelial and neurogenic conditions determine its function. Although there is available evidence supporting microvascular dysfunction as an important cause of myocardial ischaemia, with both prognostic and symptomatic implications, its diagnosis and management in clinical practice is still relegated to a second plane. Both diagnostic and therapeutic approaches are hampered by the broadness of the concept of microvascular dysfunction, which fails addressing the plurality of mechanisms leading to dysfunction. Normal microcirculatory function requires both structural integrity of the microcirculatory vascular network and preserved signalling pathways ensuring adequate and brisk arteriolar resistance shifts in response to myocardial oxygen demands. Pathological mechanisms affecting these requirements include structural remodelling of microvessels, intraluminal plugging, extravascular compression or vasomotor dysregulation. Importantly, not every diagnostic technique provides evidence on which of these pathophysiological mechanisms is present or predominates in the microcirculation. In this paper we discuss the mechanisms of coronary microvascular dysfunction and the intracoronary tools currently available to detect it, as well as the potential role of each one to unmask the main underlying mechanism.

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Fig. 1

With permission from Elsevier [15]

Fig. 2
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a lower CFR has been associated with plugging of coronary microcirculation even after successful reperfusion in STEMI patients [86]

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With permission of Springer [33]

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Abbreviations

Ach:

Acetylcholine

ACS:

Acute coronary syndrome

AMI:

Acute myocardial infarction

CAD:

Coronary artery disease

CBF:

Coronary blood flow

CFR:

Coronary flow reserve

CMR:

Cardiac magnetic resonance

CMVD:

Coronary microvascular dysfunction

cWIA:

Coronary wave intensity analysis

FFR:

Fractional flow reserve

HMR:

Hyperemic microvascular resistance

IHD:

Ischaemic heart disease

IHDVPS:

Instantaneous hyperemic diastolic velocity pressure slope

IMR:

Index of microcirculatory resistance

LVF:

Left ventricular function

MVO:

Microvascular obstruction

MVI:

Microvascular injury

NSTEMI:

Non-ST-elevated myocardial infarction

PCI:

Percutaneous coronary intervention

PET:

Positron emission tomography

Pzf:

Zero flow pressure

STEMI:

ST-elevated myocardial infarction

TMN :

Mean transit time

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Authors and Affiliations

  1. Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain

    Hernán Mejía-Rentería, Nicola Ryan & Javier Escaned

  2. Universidad Complutense de Madrid (UCM), Madrid, Spain

    Javier Escaned

  3. Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain

    Hernán Mejía-Rentería & Javier Escaned

  4. VU University Medical Centre, Amsterdam, The Netherlands

    Nina van der Hoeven, Julius Heemelaar & Niels van Royen

  5. AMC Heart Centre, Academic Medical Centre, Amsterdam, The Netherlands

    Tim P. van de Hoef

  6. Mayo Clinic, Rochester, MN, USA

    Amir Lerman

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  1. Hernán Mejía-Rentería
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Mejía-Rentería, H., van der Hoeven, N., van de Hoef, T.P. et al. Targeting the dominant mechanism of coronary microvascular dysfunction with intracoronary physiology tests. Int J Cardiovasc Imaging 33, 1041–1059 (2017). https://doi.org/10.1007/s10554-017-1136-9

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