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Updated: Jan 7, 2026
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Bridging the gap: a comprehensive toolkit for assessment of coronary microcirculation in clinical practice
Alberto Polimeni1,2, Roberto Scarsini3, Marta Belmonte4,5
1Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy.
Insights
Coronary artery disease (CAD) diagnosis is shifting from epicardial arteries to the coronary microcirculation. New invasive and non-invasive tools now allow comprehensive assessment of coronary microvascular dysfunction (CMD), improving patient care.
Area of Science:
- Cardiology
- Vascular Physiology
- Diagnostic Imaging
Background:
- Traditional coronary artery disease (CAD) management relies on epicardial artery assessment, often missing microvascular contributions to ischemia.
- Coronary microvascular dysfunction (CMD) is a significant factor in myocardial ischemia, even without obstructive epicardial disease, yet it's frequently underdiagnosed.
- Current cardiac catheterization practices lack routine assessment for CMD, limiting its clinical integration.
Purpose of the Study:
- To review the diagnostic tools and quantitative metrics for assessing coronary microvascular dysfunction (CMD).
- To highlight the clinical utility and impact of CMD assessment on patient management, especially for ischemia and nonobstructive coronary arteries (INOCA).
Main Methods:
- Exploration of emerging invasive techniques: thermodilution indices, intracoronary Doppler, and functional coronary angiography.
- Review of non-invasive modalities: cardiac MRI, PET, transthoracic Doppler echocardiography, and CT-based perfusion imaging.
- Focus on quantitative metrics for microvascular resistance, coronary flow reserve, and tissue perfusion.
Main Results:
- Invasive and non-invasive methods provide quantitative insights into microvascular physiology and tissue perfusion.
- These advanced techniques enable comprehensive evaluation of CMD, offering alternatives to catheter-based assessments.
- The integration of these tools enhances risk stratification and personalized management for patients with INOCA.
Conclusions:
- Coronary microvascular dysfunction (CMD) plays a critical role in myocardial ischemia and requires comprehensive diagnostic evaluation.
- A range of advanced invasive and non-invasive tools are now available for accurate CMD assessment.
- Integrating these diagnostic approaches improves patient management and risk stratification, particularly for those with INOCA.
Abstract:
Coronary artery disease (CAD) has traditionally been diagnosed and managed based on anatomical assessments of the epicardial coronary arteries. However, a growing body of evidence highlights the limitations of coronary angiography in evaluating the ischemic burden of atherosclerotic plaques. The coronary microcirculation is increasingly recognized for its pivotal role in myocardial ischemia. Coronary microvascular dysfunction (CMD) contributes significantly to both acute and chronic coronary syndromes, even in the absence of obstructive epicardial disease. Despite its clinical significance, CMD remains underdiagnosed due to the lack of routine assessment in contemporary cardiac catheterization practices. Emerging invasive and noninvasive techniques now enable comprehensive evaluation of coronary microvascular dysfunction (CMD) by assessing microvascular resistance, coronary flow reserve, and tissue-level perfusion. Advances in thermodilution-based indices, intracoronary Doppler, and functional coronary angiography continue to provide quantitative insights into microvascular physiology, whereas noninvasive modalities-including cardiac magnetic resonance (MRI), positron-emitted tomography (PET), transthoracic Doppler echocardiography, and computed tomography-based perfusion imaging-offer powerful tools for diagnosing CMD without the need for catheter-based assessment. Integrating these complementary approaches into clinical practice enhances risk stratification and supports personalized management strategies, particularly in patients with ischemia and nonobstructive coronary arteries (INOCA). This review explores in-depth the diagnostic tools and the quantitative metrics used or the invasive assessment of CMD, emphasizing their clinical utility and impact on patient management.
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