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Treatment of Coronary Microvascular Dysfunction

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Coronary Vasomotion Abnormalities

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Abstract

Patients with ischemia and non-obstructive coronary artery (INOCA) often have coronary microvascular dysfunction (CMD), and they are at high risk for adverse cardiac events. Nevertheless, the management of CMD represents a major unmet need because the lack of large, randomized studies makes it difficult to generate evidence-based recommendations. Recently, it was demonstrated that stratified medical therapy guided by an interventional diagnostic procedure improves health status of patients with INOCA. Accordingly, the latest guidelines state that treatment of CMD should address the dominant mechanism of microcirculatory dysfunction. In patients with impaired microcirculatory conductance and a negative acetylcholine (ACh) provocation test, beta-blockers, ACE inhibitors, and statins, along with lifestyle modifications and weight loss, are indicated. On the other hand, patients developing ECG changes and angina in response to ACh testing but without severe epicardial coronary vasoconstriction (all suggestive of microvascular spasm) may be treated mainly by calcium channel blockers. However, in patients with INOCA, coronary functional abnormalities, including epicardial coronary spasm, reduced microvascular vasodilatation, and increased microvascular resistance, frequently coexist in various combinations. Thus, in everyday clinical practice, a combination of several types of vasodilators, such as a beta-blocker and a long-acting dihydropyridine calcium channel blocker, should constitute the second step when a single drug fails to success. In cases with refractory symptoms which seriously limit life quality, analgesic drugs or non-pharmacological interventions, including rehabilitation exercise programs, spinal cord simulation, and/or psychological treatments, might be helpful. In this section, we will discuss the treatment options for CMD, taking into consideration currently accepted pathogenic mechanisms of the disorder.

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  1. Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan

    Jun Takahashi & Hiroaki Shimokawa

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    Hiroaki Shimokawa

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Takahashi, J., Shimokawa, H. (2021). Treatment of Coronary Microvascular Dysfunction. In: Shimokawa, H. (eds) Coronary Vasomotion Abnormalities. Springer, Singapore. https://doi.org/10.1007/978-981-15-7594-5_8

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