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Prognostic Impact of Coronary Microvascular Dysfunction According to Different Patterns by Invasive Physiologic
David Hong1, Doosup Shin2, Seung Hun Lee3
1Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., Y.B.S., J.-Y.H., S.-H.C., H.-C.G., J.M.L.).
Insights
Patients with coronary microvascular dysfunction and depressed coronary flow reserve (CFR) face higher risks of cardiovascular events. Elevated index of microcirculatory resistance (IMR) alone with preserved CFR has limited prognostic value.
Area of Science:
- Cardiology
- Vascular Biology
- Diagnostic Imaging
Background:
- Coronary microvascular dysfunction (CMD) is a key factor in ischemic heart disease.
- Heterogeneous patterns of CMD exist, identified by invasive indices like coronary flow reserve (CFR) and index of microcirculatory resistance (IMR).
Purpose of the Study:
- To compare the prognostic implications of different patterns of CMD defined by CFR and IMR.
- To investigate the association between specific CMD patterns and cardiovascular outcomes.
Main Methods:
- 375 patients with suspected stable ischemic heart disease and non-significant epicardial stenosis underwent invasive assessment.
- Patients were classified into four groups based on CFR (<2.5) and IMR (≥25) values.
- The primary outcome was a composite of cardiovascular death or heart failure admission.
Main Results:
- Significant differences in primary outcome incidence were observed across the four groups (20.1% to 45.0%).
- Depressed CFR was associated with a significantly higher risk of adverse outcomes, irrespective of IMR levels.
- Elevated IMR with preserved CFR did not significantly alter the risk compared to preserved CFR and low IMR.
Conclusions:
- In patients with suspected stable ischemic heart disease and non-significant epicardial stenosis, depressed CFR is a significant predictor of adverse cardiovascular events.
- Elevated IMR alone, in the context of preserved CFR, offers limited prognostic value for cardiovascular death or heart failure admission.
Background:
Coronary microvascular dysfunction is a clinically significant component of ischemic heart disease. There can be heterogenous patterns of coronary microvascular dysfunction defined by invasive physiologic indexes such as coronary flow reserve (CFR) and index of microcirculatory resistance (IMR). We sought to compare the prognosis of coronary microvascular dysfunction according to different patterns of CFR and IMR.
Methods:
The current study included 375 consecutive patients undergoing invasive physiologic assessment for suspected stable ischemic heart disease and intermediate but functionally nonsignificant epicardial stenosis (fractional flow reserve, >0.80). According to cutoff values of invasive physiologic indexes reflecting microcirculatory function (CFR, <2.5; IMR, ≥25), patients were classified into 4 groups: (1) preserved CFR and low IMR (group 1), (2) preserved CFR and elevated IMR (group 2), (3) depressed CFR and low IMR (group 3), and (4) depressed CFR and elevated IMR (group 4). Primary outcome was a composite of cardiovascular death or admission for heart failure during the follow-up time.
Results:
Cumulative incidence of the primary outcome was significantly different among the 4 groups (group 1, 20.1%; group 2, 18.8%; group 3, 33.9%; and group 4, 45.0%; overall P<0.001). Depressed CFR had significantly higher risk of primary outcome than preserved CFR in both low (hazard ratio [HR], 1.894 [95% CI, 1.112-3.225]; P=0.019) and elevated IMR subgroups (HR, 3.307 [95% CI, 1.519-7.202]; P=0.003). Conversely, the risk of primary outcome was not significantly different between elevated and low IMR in preserved CFR subgroups (HR, 0.926 [95% CI, 0.428-2.005]; P=0.846). Furthermore, as continuous variables, IMR-adjusted CFR (adjusted HR, 0.644 [95% CI, 0.537-0.772]; P<0.001) was significantly associated with the risk of primary outcome but CFR-adjusted IMR (adjusted HR, 1.004 [95% CI, 0.992-1.016]; P=0.515) was not.
Conclusions:
Among patients with suspected stable ischemic heart disease who were found to have an intermediate but functionally nonsignificant epicardial stenosis, depressed CFR was associated with an increased risk of cardiovascular death and admission for heart failure. However, elevated IMR alone with preserved CFR showed limited prognostic value in this population.
Registration:
URL: https://www.
Clinicaltrials:
gov; Unique identifier: NCT05058833.
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