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Coronary Microcirculation: A Clinical Perspective

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PanVascular Medicine

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Abstract

The coronary microcirculation extends far beyond the epicardial coronary vasculature and cannot be directly visualized with conventional angiography; its evaluation relies largely on functional assessment techniques. After several years of research into its functional and structural abnormalities, we have gained a better insight into the significance of the coronary microcirculation. Coronary microvascular dysfunction can lead to myocardial ischemia, often mimicking obstructive coronary artery disease. Increased coronary microvascular resistance can impair coronary blood flow and trigger angina symptoms, ischemic electrocardiographic changes, and myocardial perfusion defects and lead to left ventricular dysfunction in patients with unobstructed epicardial coronary arteries. Cardiac syndrome X is a well-described clinical condition characterized by typical effort-induced angina and ST-segment depression on exercise testing in the absence of obstructive coronary artery disease. Coronary microvascular dysfunction encompassing several pathogenic mechanisms appears to be the cause of the syndrome. Importantly, however, coronary microvascular dysfunction can occur in the context of other cardiac disease processes. There is a growing interest in the documentation of coronary microvascular dysfunction in the context of established epicardial coronary artery disease and acute myocardial infarction mainly due to its prognostic implications in the latter. This chapter focuses on the diagnostic assessment of coronary microvascular dysfunction and the different clinical contexts in which it may be observed. A section of this chapter has been dedicated specifically to cardiac syndrome X – a paradigmatic condition often referred to as “chest pain with normal coronary arteries” which encompasses patients with different forms of coronary microvascular dysfunction.

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Abbreviations

Acute coronary syndrome:

A clinical condition encompassing acute chest pain at rest, electrocardiographic changes suggestive of myocardial ischemia or necrosis, and/or raised markers of myocardial damage.

Angina pectoris:

Chest pain due to insufficient myocardial blood flow.

Cardiac syndrome X:

Angina pectoris despite normal/unobstructed coronary arteries.

Coronary angiography:

Invasive imaging technique using the principles of X-ray to evaluate the anatomical status of the coronary arteries.

Coronary artery spasm:

A severe but reversible constriction of the epicardial coronary arteries, evoking acute myocardial ischemia.

Coronary microcirculation:

Vascular networks within the heart muscle through which blood is transported through the myocardium to supply oxygen to myocardial cells and eliminate metabolic waste from the heart; an active site of blood flow control as well as metabolic activity.

Coronary microvascular dysfunction:

Abnormal function of the coronary microcirculation often caused by endothelial cell dysfunction.

Hyperemia:

The result of a regulatory response to allow increased blood supply to different tissues through vasodilation.

Index of microvascular resistance (IMR):

A validated measure of the function of the coronary microcirculation.

Intracoronary provocation testing:

Invasive technique to assess provoked coronary artery spasm during coronary angiography.

Intravascular ultrasound:

Invasive imaging technique utilizing ultrasound technology to assess the lumen of the blood vessels.

Myocardial ischemia:

A condition that results from insufficient blood flow reaching the myocardium via the coronary arteries.

Percutaneous coronary intervention:

A catheter-based nonsurgical procedure used to remove atheromatous obstructions blocking the coronary arteries.

Perfusion cardiac magnetic resonance:

Noninvasive imaging modality used to assess perfusion defects in the left ventricular myocardium.

Positron emission tomography:

Noninvasive imaging technique utilizing short-lived radiolabeled substances to produce high-resolution images of the body’s metabolic function.

Reperfusion injury:

A condition in which the restoration of blood circulation to an ischemic tissue results in inflammation and oxidative damage through the induction of oxidative stress.

ST-segment elevation myocardial infarction:

Usually reflects acute thrombotic coronary artery occlusion resulting in characteristic electrocardiographic ST-segment elevation.

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Authors and Affiliations

  1. Cardiovascular and Cell Sciences Research Institute, St George’s, University of London, Cranmer Terrace, SW17 0RE, London, UK

    Sofia A. Papadopoulou & Juan Carlos Kaski

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  1. Sofia A. Papadopoulou
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  2. Juan Carlos Kaski
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Correspondence to Juan Carlos Kaski .

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  1. Division of Cardiovascular Disease Department of Internal Medicine, Health Care Center Bitterfeld, Bitterfeld-Wolfen, Germany

    Peter Lanzer

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Papadopoulou, S.A., Kaski, J.C. (2015). Coronary Microcirculation: A Clinical Perspective. In: Lanzer, P. (eds) PanVascular Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-37078-6_28

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