Noninvasive techniques to assess myocardial ischemia in hypertensive patients
Riccardo Rambaldi1, Riccardo Bigi, Cesare Fiorentini
1Maggiore Hospital, Bologna, Department of Cardiology, Bologna, Italy.
Insights
Hypertension significantly increases coronary artery disease (CAD) risk. While exercise ECG is useful, advanced imaging and coronary flow reserve (CFR) quantification offer better diagnosis and prognosis for hypertensive heart disease.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Hypertension Research
Background:
- Hypertensive patients exhibit a higher prevalence and severity of coronary artery disease (CAD) compared to normotensive individuals.
- Established diagnostic methods for myocardial ischemia in hypertensive patients with suspected CAD exist, with exercise electrocardiogram (ECG) playing a key role under physiologic conditions.
Purpose of the Study:
- To review current and emerging diagnostic techniques for CAD in hypertensive patients.
- To highlight the role of advanced imaging and coronary flow reserve (CFR) in managing hypertensive heart disease.
Main Methods:
- Review of established and novel diagnostic modalities for CAD, including exercise ECG, myocardial SPECT, stress echocardiography, MRI, PET, and CT.
- Focus on the emerging role of noninvasive techniques for assessing coronary flow reserve (CFR) and microcirculatory dysfunction.
Main Results:
- Exercise ECG is valuable but has suboptimal specificity, necessitating further investigation with more specific imaging techniques like SPECT and stress echocardiography.
- Coronary angiography remains the gold standard for epicardial CAD assessment, but microcirculatory dysfunction and CFR quantification are emerging as crucial for prognostication and treatment decisions in hypertensive hearts.
Conclusions:
- Advanced imaging techniques and CFR quantification are vital for accurate CAD diagnosis, risk stratification, and guiding revascularization in hypertensive patients.
- Microcirculatory dysfunction, even with normal epicardial arteries, is a significant prognostic factor and a potential future therapeutic target in hypertensive heart disease.
Abstract:
Hypertensive patients are more affected by coronary artery disease (CAD) than normotensive patients. Currently, established techniques are able to diagnose myocardial ischemia/CAD in hypertensive patients with suspected CAD. An irrevocable role remains for exercise electrocardiogram (ECG) owing to the many parameters evaluated under physiologic conditions. However, the suboptimal specificity of a positive exercise ECG demands further examination of hypertensive patients with either myocardial single-photon emission computed tomography (SPECT) or stress echocardiography, both more specific than exercise ECG in diagnosing CAD. The high specificity of imaging techniques also makes them highly predictive of cardiac events. Additional techniques to help diagnose CAD are available. Tissue Doppler imaging, strain and other echo-derived techniques may add quantitative elements to recognize CAD in hypertensive hearts. The accuracy of MRI is improving to study myocardial function and perfusion. Positron emission tomography and multislice computed tomography, also in-built with fusion scanners, are playing roles in combining coronary angiography and myocardial function/ischemia assessment. However, no significant application of these additional techniques is available for hypertensive patients. Epicardial CAD assessed by coronary angiography remains the gold standard to decide for revascularization procedures. The presence of microcirculatory dysfunction, a symptom typical of hypertensive hearts, is opening up new areas of noninvasive diagnostic techniques for the detection of coronary flow reserve (CFR) and related myocardial ischemia. The quantification of CFR may render this parameter pivotal to deciding the need for revascularization procedures of intermediate coronary stenosis and it may become an additional gold standard in evaluating coronary vessels. Moreover, even with normal epicardial coronary arteries, microcirculation dysfunction bears prognostic stratification capabilities for hypertensive patients and it may become a promising therapeutic target in the near future.
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