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Invasive Assessment of Coronary Microcirculation: A State-of-the-Art Review
Luca Ciaramella1, Luigi Di Serafino1, Lucia Mitrano1
1Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy.
Insights
Coronary microvascular dysfunction (CMD) causes ischemia symptoms in patients without significant blockages. Invasive assessment guides diagnosis and treatment for this underdiagnosed condition, improving patient quality of life.
Area of Science:
- Cardiology
- Vascular Biology
- Diagnostic Imaging
Background:
- Many patients with myocardial ischemia symptoms lack significant epicardial coronary artery disease.
- Coronary microvascular dysfunction (CMD) is increasingly recognized as a cause of ischemia in these patients.
- CMD diagnosis is challenging due to small vessel size and invasive testing limitations.
Purpose of the Study:
- To analyze the pathophysiology of coronary microvascular dysfunction (CMD).
- To provide a guide for the invasive assessment of coronary microcirculation.
- To review the clinical evidence supporting the use of invasive assessment for CMD.
Main Methods:
- Literature review on CMD pathophysiology.
- Description of invasive techniques for coronary microcirculation assessment.
- Analysis of clinical studies evaluating the impact of CMD assessment.
Main Results:
- CMD is a significant contributor to ischemic symptoms in patients with non-obstructive coronary artery disease.
- Invasive physiological assessment offers a "full physiology" approach to evaluate the entire coronary vasculature.
- Evidence supports the benefit of this approach in improving symptoms.
Conclusions:
- CMD is underdiagnosed and undertreated, leading to persistent symptoms and reduced quality of life.
- Invasive assessment of coronary microcirculation is crucial for accurate CMD diagnosis and management.
- A comprehensive physiological approach can improve outcomes for patients with ischemia and non-obstructive coronary artery disease.
Abstract:
A significant proportion of patients presenting with signs and symptoms of myocardial ischemia have no "significant" epicardial disease; thereby, the assessment of coronary microcirculation gained an important role in improving diagnosis and guiding therapy. In fact, coronary microvascular dysfunction (CMD) could be found in a large proportion of these patients, supporting both symptoms and signs of myocardial ischemia. However, CMD represents a diagnostic challenge for two main reasons: (1) the small dimension of the coronary microvasculature prevents direct angiographic visualization, and (2) despite the availability of specific diagnostic tools, they remain invasive and underused in the current clinical practice. For these reasons, CMD remains underdiagnosed, and most of the patients remain with no specific treatment and quality-of-life-limiting symptoms. Of note, recent evidence suggests that a "full physiology" approach for the assessment of the whole coronary vasculature may offer a significant benefit in terms of symptom improvement among patients presenting with ischemia and non-obstructive coronary artery disease. We analyze the pathophysiology of coronary microvascular dysfunction, providing the readers with a guide for the invasive assessment of coronary microcirculation, together with the available evidence supporting its use in clinical practice.
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