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Myocardial Ischemia: Differentiating between Epicardial Coronary Artery Atherosclerosis, Microvascular Dysfunction
Giovanni Monizzi1, Francesca Di Lenarda1, Emanuele Gallinoro1
1Division of University Cardiology, IRCCS Ospedale Galeazzi-Sant'Ambrogio, 20157 Milan, Italy.
Insights
Ischemic heart disease is a global health issue. This review clarifies diagnosis for myocardial ischemia, focusing on non-obstructive coronary artery disease (INOCA) and coronary microvascular dysfunction (CMD).
Area of Science:
- Cardiology
- Internal Medicine
- Diagnostic Imaging
Background:
- Ischemic heart disease is a leading cause of global mortality.
- A significant portion of patients with suspected ischemia lack obstructive coronary artery disease (CAD).
- Ischemia with non-obstructive coronary artery disease (INOCA) has been historically under-recognized due to unclear prognostic implications.
Purpose of the Study:
- To differentiate patterns of myocardial ischemia.
- To highlight diagnostic approaches for epicardial obstructive CAD, coronary microvascular dysfunction (CMD), and vasomotor abnormalities.
- To review the current diagnostic state-of-the-art for these conditions.
Main Methods:
- Literature review of diagnostic strategies for myocardial ischemia.
- Analysis of studies differentiating obstructive CAD from INOCA.
- Examination of diagnostic criteria for coronary microvascular dysfunction and vasomotor abnormalities.
Main Results:
- Myocardial ischemia can stem from obstructive CAD, CMD, or vasomotor issues.
- Accurate diagnosis requires differentiating these causes.
- Recent advancements clarify the prognostic significance of INOCA.
Conclusions:
- Recognizing diverse causes of myocardial ischemia is crucial.
- Advanced diagnostic techniques are essential for identifying INOCA and CMD.
- Improved diagnostic clarity enhances patient management and prognosis.
Abstract:
Ischemic heart disease is currently the most common cause of mortality and morbidity worldwide. Although myocardial ischemia is classically determined by epicardial coronary atherosclerosis, up to 40% of patients referred for coronary angiography have no obstructive coronary artery disease (CAD). Ischemia with non-obstructive coronary artery disease (INOCA) has typically been underestimated in the past because, until recently, its prognostic significance was not completely clear. This review aims to highlight differences and patterns in myocardial ischemia caused by epicardial obstructive CAD, coronary microvascular dysfunction (CMD) or vasomotor abnormalities and to elucidate the state of the art in correctly diagnosing these different patterns.
