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Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Targeting the dominant mechanism of coronary microvascular dysfunction with intracoronary physiology tests
Hernán Mejía-Rentería1,2, Nina van der Hoeven3, Tim P van de Hoef4
1Hospital Clínico Universitario San Carlos, 28040, Madrid, Spain.
Insights
Coronary microvascular dysfunction is a key cause of myocardial ischemia, yet its diagnosis and management are often overlooked. This review details its mechanisms and intracoronary diagnostic tools.
Area of Science:
- Cardiovascular Medicine
- Physiology
Background:
- The coronary microcirculation is crucial for myocardial blood supply, influenced by oxygen demand and endothelial/neurogenic factors.
- Microvascular dysfunction is linked to myocardial ischemia, impacting prognosis and symptoms, but clinical diagnosis and management remain underdeveloped.
- Current understanding is limited by the broad concept of microvascular dysfunction, obscuring diverse underlying mechanisms.
Purpose of the Study:
- To elucidate the mechanisms of coronary microvascular dysfunction.
- To review intracoronary tools for detecting coronary microvascular dysfunction.
- To assess the utility of these tools in identifying specific pathophysiological mechanisms.
Main Methods:
- Review of existing literature on coronary microvascular function and dysfunction.
- Discussion of pathological mechanisms affecting microcirculation (e.g., structural remodeling, vasomotor dysregulation).
- Analysis of intracoronary diagnostic techniques and their ability to differentiate underlying causes.
Main Results:
- Normal microcirculation depends on structural integrity and responsive signaling pathways.
- Pathologies include microvessel remodeling, intraluminal plugging, extravascular compression, and vasomotor dysregulation.
- Existing diagnostic methods vary in their capacity to pinpoint specific pathophysiological drivers of dysfunction.
Conclusions:
- Coronary microvascular dysfunction is a significant contributor to myocardial ischemia.
- A comprehensive understanding of its diverse mechanisms is essential for effective clinical practice.
- Intracoronary tools offer potential for mechanism-based diagnosis, guiding targeted therapeutic strategies.
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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