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Coronary Microvascular Dysfunction in Patients With Heart Failure: Characterization of Patterns in HFrEF Versus HFpEF
Pasquale Paolisso1,2, Emanuele Gallinoro1,3, Marta Belmonte1,2
1Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.).
Insights
Coronary microvascular dysfunction (CMD) impacts heart failure (HF) progression. Invasive assessment revealed distinct CMD patterns in HF with preserved ejection fraction and HF with reduced ejection fraction (HFrEF), predicting reverse remodeling in HFrEF.
Area of Science:
- Cardiology
- Cardiovascular Research
- Heart Failure Pathophysiology
Background:
- Coronary microvascular dysfunction (CMD) is a key factor in heart failure (HF) development and worsening.
- CMD affects HF regardless of ejection fraction or obstructive coronary artery disease.
- Invasive assessment of CMD offers valuable insights into HF phenotyping and patient prognosis.
Purpose of the Study:
- To invasively assess coronary flow, microvascular resistance, myocardial perfusion, and reserves in HF patients.
- To differentiate CMD patterns in HF with preserved ejection fraction (HFpEF) versus HF with reduced ejection fraction (HFrEF).
Main Methods:
- A prospective study of 56 HF patients (21 HFpEF, 35 HFrEF) with nonobstructive coronary artery disease.
- Invasive assessment of CMD using continuous intracoronary thermodilution, defining CMD as coronary flow reserve <2.5.
- Quantification of myocardial mass and calculation of myocardial perfusion via echocardiography, CT angiography, and coronary flow measurements.
Main Results:
- HFrEF patients had significantly higher myocardial mass compared to HFpEF patients.
- Overall, 52% of patients exhibited CMD, with similar prevalence across HF phenotypes.
- In HFrEF, CMD presented as functional (low resistance, high flow at rest); in HFpEF, it was structural (high resistance, low flow during hyperemia).
- CMD independently predicted reduced left ventricular reverse remodeling in HFrEF.
Conclusions:
- Continuous intracoronary thermodilution effectively defines and characterizes distinct CMD patterns in HF.
- This method can identify HFrEF patients at higher risk for impaired left ventricular reverse remodeling.
Background:
Coronary microvascular dysfunction (CMD) is involved in heart failure (HF) onset and progression, independently of HF phenotype and obstructive coronary artery disease. Invasive assessment of CMD might provide insights into phenotyping and prognosis of patients with HF. We aimed to assess absolute coronary flow, absolute microvascular resistance, myocardial perfusion, coronary flow reserve, and microvascular resistance reserve in patients with HF with preserved ejection fraction and HF with reduced ejection fraction (HFrEF).
Methods:
Single-center, prospective study of 56 consecutive patients with de novo HF with nonobstructive coronary artery disease divided into HF with preserved ejection fraction (n=21) and HFrEF (n=35). CMD was invasively assessed by continuous intracoronary thermodilution and defined as coronary flow reserve <2.5. Left ventricular and left anterior descending artery-related myocardial mass was quantified by echocardiography and coronary computed tomography angiography. Myocardial perfusion (mL/min per g) was calculated as the ratio between absolute coronary flow and left anterior descending artery-related mass.
Results:
Patients with HFrEF showed a higher left ventricular and left anterior descending artery-related myocardial mass compared with HF with preserved ejection fraction (P<0.010). Overall, 52% of the study population had CMD, with a similar prevalence between the 2 groups. In HFrEF, CMD was characterized by lower absolute microvascular resistance and higher absolute coronary flow at rest (functional CMD; P=0.002). CMD was an independent predictor of a lower rate of left ventricular reverse remodeling at follow-up. In patients with HF with preserved ejection fraction, CMD was mainly due to higher absolute microvascular resistance and lower absolute coronary flow during hyperemia (structural CMD; P≤0.030).
Conclusions:
Continuous intracoronary thermodilution allows the definition and characterization of patterns with distinct CMD in patients with HF and could identify patients with HFrEF with a higher rate of left ventricular reverse remodeling at follow-up.
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