Physiological Stratification of Patients With Angina Due to Coronary Microvascular Dysfunction

Coronary microvascular dysfunction (CMD) is defined by diminished flow reserve. Functional and structural CMD endotypes have recently been described, with normal and elevated minimal microvascular resistance, respectively. This study determined the mechanism of altered resting and maximal flow in CM...

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Published in:Journal of the American College of Cardiology 2020-05, Vol.75 (20), p.2538-2549
Main Authors: Rahman, Haseeb, Demir, Ozan M., Khan, Faisal, Ryan, Matthew, Ellis, Howard, Mills, Mark T., Chiribiri, Amedeo, Webb, Andrew, Perera, Divaka
Format: Article
Language:English
Subjects:
Adenosine - chemistry
Aged
Angina Pectoris - diagnosis
Angina Pectoris - physiopathology
Biomarkers - metabolism
Blood Flow Velocity
Coronary Angiography
Coronary Artery Disease - physiopathology
Coronary Circulation
coronary flow reserve
Coronary Vessels - physiopathology
endothelial dysfunction
Endothelium, Vascular - metabolism
Exercise
Female
Humans
Hyperemia - metabolism
Male
Microcirculation
microvascular dysfunction
Middle Aged
Myocardial Ischemia - physiopathology
nitric oxide
Nitric Oxide Synthase - metabolism
Plethysmography
Reference Values
stratified medicine
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Summary:Coronary microvascular dysfunction (CMD) is defined by diminished flow reserve. Functional and structural CMD endotypes have recently been described, with normal and elevated minimal microvascular resistance, respectively. This study determined the mechanism of altered resting and maximal flow in CMD endotypes. A total of 86 patients with angina but no obstructive coronary disease underwent coronary pressure and flow measurement during rest, exercise, and adenosine-mediated hyperemia and were classified as the reference group or as patients with CMD by a coronary flow reserve threshold of 2.5; functional or structural endotypes were distinguished by a hyperemic microvascular resistance threshold of 2.5 mm Hg/cm/s. Endothelial function was assessed by forearm blood flow (FBF) response to acetylcholine, and nitric oxide synthase (NOS) activity was defined as the inverse of FBF reserve to NG-monomethyl-L-arginine. Of the 86 patients, 46 had CMD (28 functional, 18 structural), and 40 patients formed the reference group. Resting coronary blood flow (CBF) (24.6 ± 2.0 cm/s vs. 16.6 ± 3.9 cm/s vs. 15.1 ± 4.7 cm/s; p 
ISSN:0735-1097
1558-3597
DOI:10.1016/j.jacc.2020.03.051