Myocardial Small Vessel Disease and Endothelial Dysfunction

  • P. Elliott MillerEmail author
Part of the Contemporary Cardiology book series (CONCARD)


Health-care providers are often confronted with patients that present with anginal symptoms, but on coronary angiography are found to have nonobstructive coronary artery disease (CAD) (Patel et al., N Engl J Med 362:886–895, 2010). Many times, chest pain in these patients may be attributed to non-cardiac causes, such as musculoskeletal pain or pathology in the gastrointestinal or pulmonary systems. However, myocardial small vessel disease, also called coronary microvascular dysfunction (CMD) or cardiac syndrome X, is an increasingly recognized disorder in those with nonobstructive CAD (Camici and Crea, Eur Heart J 356:830–840, 2007; Crea et al., Eur Heart J 35:1101–1111, 2014; Lanza and Crea, Circulation 121:2317–2325, 2010).

The prevalence of CMD has been estimated to be at least 3–4 million individuals in the United States with a predominance of women (Crea et al., Eur Heart J 35:1101–1111, 2014). Risk factors for CMD are similar to those that predispose to atherosclerosis, including diabetes, hypertension, chronic inflammation, cigarette smoking, dyslipidemia, and insulin resistance (Camici and Crea, Eur Heart J 356:830–840, 2007; Crea et al., Eur Heart J 35:1101–1111, 2014). The pathophysiology of this heterogeneous group of disorders is controversial and likely multifactorial. Proposed mechanisms include endothelial dysfunction (both abnormal response to vasodilators and increased response to vasoconstrictors), smooth muscle hypertrophy, and increased pain perception (Lanza and Crea, Circulation 121:2317–2325, 2010). While those with nonobstructive CAD have previously been considered low risk, emerging evidence suggests higher rates of recurrent angina, ongoing anxiety, reduced exercise tolerance, poorer quality of life, and cardiovascular disease (CVD) events (Jespersen et al., Eur Heart J 33:734–744, 2012; Johnson et al., Circulation 109:2993–2999, 2004; Olson et al., Eur Heart J 24:1506–1514, 2003).


Myocardial small vessel disease Coronary microvascular disease Endothelial dysfunction 


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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Division of Cardiovascular MedicineYale University School of MedicineNew HavenUSA

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