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The significance of coronary reserve in clinical heart disease
1Department of Internal Medicine, University of Düsseldorf, Federal Republic of Germany.
Insights
Coronary insufficiency with normal coronary arteriogram often involves microcirculation issues. Early detection and treatment of underlying vascular, rheologic, or metabolic disorders are crucial for managing persistent angina.
Area of Science:
- Cardiology
- Vascular Biology
- Internal Medicine
Background:
- Coronary insufficiency with a normal coronary arteriogram affects 10-20% of patients with exercise-induced symptoms.
- This condition is frequently linked to disturbances in the coronary microcirculation.
Purpose of the Study:
- To investigate the causes and diagnostic approaches for coronary insufficiency in patients with normal coronary arteriograms.
- To highlight the importance of assessing coronary microcirculation for effective patient management.
Main Methods:
- Utilized standard diagnostic procedures like electrocardiograms and exercise tests.
- Employed advanced functional assessments including coronary blood flow, vascular reserve, lactate production, serology, and viscosity measurements.
- Examined peripheral arteries via histology and immune histology.
Main Results:
- Identified microcirculatory disturbances in most patients with normal coronary arteriograms.
- Linked these disturbances to various vascular diseases (hypertension, immunopathies), rheologic diseases (paraproteinemia, hyperlipoproteinemia), and oxygen transport issues (CO intoxication, methemoglobinemia).
Conclusions:
- Persistent angina with normal coronary arteriograms necessitates further investigation into microcirculatory function.
- Management should focus on treating the underlying vascular, rheologic, and metabolic disorders contributing to coronary microcirculation dysfunction.
Abstract:
The clinical syndrome "coronary insufficiency with normal coronary arteriogram" is found in approximately 10% to 20% of patients with exercise-induced coronary insufficiency. In most of these cases, disturbances of the coronary microcirculation are present. They can appear in vascular diseases (arterial hypertension, systemic immunopathies, immune complex vasculitis), in rheologic diseases (paraproteinemia, hyperlipoproteinemia, polyglobulia) and in disturbances of transport and diffusion of oxygen (carbon monoxide intoxication, methemoglobinemia). The clinical diagnosis is based on the usual diagnostic procedures (electrocardiogram, exercise electrocardiogram, responsiveness to nitroglycerin), as well as on newer functionally oriented diagnostic procedures (determinations of coronary blood flow and coronary vascular reserve, production of lactate, serologic findings, histology and immune histology of peripheral arteries, measurements of viscosities in both plasma and blood). Many clinically relevant disturbances in the coronary microcirculation can thus be detected and treated on a rational basis by management of the underlying main disease, that is, by treatment of the vascular, rheologic and metabolic disorders. Persistent angina pectoris in the presence of a normal coronary arteriogram does not represent an end to coronary diagnostic procedures, but introduces the clinical task of using all diagnostic possibilities to enable functional and therapeutic assessment of the coronary microcirculation.