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Published on: August 17, 2022
Coronary microvascular dysfunction: a narrative review
Joseph M O'Brien1,2, Thomas J Ford3,4, Andy Yong5,6
1Monash Heart, Victorian Heart Hospital, Monash Health, Melbourne, VIC, Australia.
Insights
Coronary microvascular dysfunction (CMD) is increasingly recognized but hard to diagnose. New research explores non-invasive methods and links CMD to inflammation, offering hope for better treatments and outcomes.
Area of Science:
- Cardiology
- Vascular Biology
- Diagnostic Imaging
Background:
- Coronary microvascular dysfunction (CMD) affects the heart's small arteries, mimicking macrovascular disease.
- Current diagnosis via invasive coronary angiography (ICA) is limited, leading to underdiagnosis.
- Growing clinical interest is reflected in international guidelines.
Purpose of the Study:
- To provide a comprehensive review of recent research on CMD.
- To outline pathophysiology, diagnostic advancements, prognosis, and treatment options.
- To highlight future research and management directions.
Main Methods:
- Systematic literature search of PubMed (1990-2024).
- Inclusion of original research, reviews, and consensus documents.
- Independent article selection by two reviewers.
Main Results:
- CMD incidence is rising with improved diagnostic tools.
- Consider CMD in angina patients without obstructive CAD on ICA/CT.
- Emerging non-invasive diagnostics and links to inflammation as a therapeutic target.
- CMD impacts quality of life and increases cardiovascular event risk.
- Limited medical options with variable responses.
Conclusions:
- CMD is heterogeneous, posing diagnostic and therapeutic challenges.
- Research focuses on non-invasive diagnostics and novel therapies.
- Large trials are needed to validate new approaches and improve outcomes.
Background And Objective:
Coronary microvascular dysfunction (CMD) describes pathology within the microcirculation of the coronary arterial tree. Patients with this condition present similarly to macrovascular coronary disease, and it remains challenging to diagnose using invasive coronary angiography (ICA) alone. CMD is a cause of frequent hospital separations, and due to limitations in existing diagnostic techniques goes under-diagnosed. There is increasing interest amongst specialists, as reflected in recent American, European, and Japanese guidelines. This review seeks to present a thorough overview of recent research on CMD, outlining its pathophysiology, diagnostic insights, prognosis, available treatment options, and future directions of research and management.
Methods:
A systematic search of PubMed [1990-2024] was conducted, including English-language original research, reviews, and consensus documents. Articles were selected independently by two reviewers.
Key Content And Findings:
The incidence of CMD is increasing due to greater recognition and improved availability of coronary physiological assessment. CMD should be considered in patients with symptoms of angina without obstructive coronary artery disease (CAD) identified on ICA or computed tomography (CT). In addition to existing invasive techniques, non-invasive methods of diagnosis are emerging. There is a substantial body of evidence linking CMD with inflammatory conditions, potentially making this pathway a novel therapeutic target. Previously thought to bear no mortality effect, registry data is showing reduction in not only quality of life metrics but elevated risk of cardiovascular events in this cohort. Medical options are limited, with variable patient response.
Conclusions:
CMD is a heterogeneous condition presenting diagnostic challenges, refractory symptoms, and evolving recognition of its prognostic significance. Emerging research focuses on non-invasive diagnostics and novel therapies to bridge treatment gaps. Large-scale trials are needed to assess their impact on clinical outcomes.
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