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Primary versus iatrogenic (post-PCI) coronary microvascular dysfunction: a wire-based multimodal comparison

Hakan Hasdemir1, Ahmet Taş2,3, Erdem Cevik4

  • 1Department of Cardiology, Acibadem Atakent Hospital, Istanbul, Turkey.

Open Heart
|November 27, 2023
PubMed
Abstract

Insights

Coronary microvascular dysfunction (CMD) in non-obstructed arteries (Type-1 CMD) shows more severe microvascular impairment than PCI-induced CMD (Type-4 CMD), despite similar ischemia severity.

Area of Science:

  • Cardiology
  • Vascular Biology
  • Internal Medicine

Background:

  • Coronary microvascular dysfunction (CMD) is increasingly recognized in various clinical settings.
  • Distinguishing between different CMD subtypes, such as ischemia in non-obstructed coronary arteries (INOCA, Type-1 CMD) and percutaneous coronary intervention (PCI)-induced CMD (Type-4 CMD), is crucial.
  • Limited data exist comparing the severity and characteristics of Type-1 and Type-4 CMD.

Purpose of the Study:

  • To comparatively analyze the coronary hemodynamic, thermodynamic, and electrocardiographic characteristics of Type-1 CMD and Type-4 CMD.
  • To elucidate the distinct pathophysiological mechanisms underlying these two CMD subtypes.
  • To provide a comprehensive comparison of microvascular impairment in INOCA versus post-PCI settings.

Main Methods:

  • A comparative analysis of wire-based multimodal perfusion markers was performed in 35 patients.
  • Patients were categorized into INOCA/CMD (Type-1) and stented coronary artery/PCI (Type-4) groups.
  • Coronary flow reserve (CFR) <2.5 defined CMD; intracoronary ECG, hemodynamic, and thermodynamic parameters were assessed.

Main Results:

  • Both Type-1 and Type-4 CMD groups exhibited similarly blunted CFR values and hyperemic ST shifts.
  • Type-1 CMD was associated with impaired hyperemic blood flow acceleration and attenuated diastolic microvascular decompression waves, alongside higher hyperemic microvascular resistance.
  • Type-4 CMD showed blunted CFR primarily due to higher baseline flow velocity from post-occlusive reactive hyperemia.

Conclusions:

  • Microvascular dysfunction in the INOCA setting (Type-1 CMD) appears more pronounced than that following elective PCI (Type-4 CMD).
  • Despite differing microvascular characteristics, both CMD subtypes result in equally severe reversible ischemia in the downstream myocardium.
  • These findings highlight distinct pathophysiological pathways for Type-1 and Type-4 CMD, impacting therapeutic strategies.
Keywords:
coronary vesselsmicrovascular anginapercutaneous coronary intervention

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