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Reappraisal of Ischemic Heart Disease: Fundamental Role of Coronary Microvascular Dysfunction in the Pathogenesis of Angina Pectoris

Kaski, J-C; Crea, F; Gersh, BJ; Camici, PG (2018) Reappraisal of Ischemic Heart Disease: Fundamental Role of Coronary Microvascular Dysfunction in the Pathogenesis of Angina Pectoris. CIRCULATION, 138 (14). pp. 1463-1480. ISSN 0009-7322 https://doi.org/10.1161/CIRCULATIONAHA.118.031373
SGUL Authors: Kaski, Juan Carlos

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Abstract

In recent years, it has become apparent that coronary microvascular dysfunction plays a pivotal pathogenic role in angina pectoris. Functional and structural mechanisms can affect the physiological function of the coronary microvasculature and lead to myocardial ischemia in people without coronary atheromatous disease and also in individuals with obstructive coronary artery disease. Abnormal dilatory responses of the coronary microvessels, coronary microvascular spasm, and extravascular compressive forces have been identified as pathogenic mechanisms in both chronic and acute forms of ischemic heart disease. The condition characterized by anginal symptoms and evidence of myocardial ischemia triggered by coronary microvascular dysfunction, in the absence of obstructive coronary disease, is known as microvascular angina. The concept of microvascular angina, however, may extend further to include patients with obstructive coronary artery disease and individuals with angina after coronary revascularization or heart transplantation because coronary microvascular dysfunction contributes to myocardial ischemia in many such patients. Patients with microvascular angina constitute a sizeable proportion of all cases of stable angina undergoing diagnostic coronary angiography and of those with persisting angina after successful coronary revascularization. Coronary microvascular dysfunction is also often responsible for angina in individuals with cardiomyopathy and heart valve disease as well as acute coronary syndrome cases such as Takotsubo syndrome and myocardial infarction with no obstructive coronary artery disease. Patients with stable microvascular angina present typically with effort or rest chest pain and a reduced coronary flow reserve or microvascular spasm. This condition, which affects women and men, can markedly impair quality of life and prognosis and represents a substantial cost burden to healthcare systems and individuals alike. In recent years, progress in the diagnosis of myocardial ischemia and the use of tests to investigate functional and structural causes for a reduced coronary flow reserve and microvascular spasm have allowed the identification of an increased number of cases of microvascular angina in everyday clinical practice. Although some of the available anti-anginal drugs may be helpful, treatment of coronary microvascular dysfunction remains a major challenge. The present article discusses the fundamental role that coronary microvascular dysfunction plays in the pathogenesis of ischemic heart disease, the clinical characteristics of patients presenting with microvascular angina, and possible diagnostic and therapeutic strategies.

Item Type: Article
Additional Information: This is a non-final version of an article published in final form in Kaski, J-C; Crea, F; Gersh, BJ; Camici, PG (2018) Reappraisal of Ischemic Heart Disease: Fundamental Role of Coronary Microvascular Dysfunction in the Pathogenesis of Angina Pectoris. CIRCULATION, 138 (14). pp. 1463-1480
Keywords: cardiac imaging, coronary circulation, coronary microvascular dysfunction, ischemic heart disease, microvascular angina, cardiac imaging, coronary circulation, coronary microvascular dysfunction, ischemic heart disease, microvascular angina, 1103 Clinical Sciences, 1102 Cardiovascular Medicine And Haematology, 1117 Public Health And Health Services, Cardiovascular System & Hematology
SGUL Research Institute / Research Centre: Academic Structure > Molecular and Clinical Sciences Research Institute (MCS)
Journal or Publication Title: CIRCULATION
ISSN: 0009-7322
Dates:
DateEvent
2 October 2018Published
1 October 2018Published Online
20 August 2018Accepted
Publisher License: Publisher's own licence
Web of Science ID: WOS:000446002500010
URI: https://openaccess.sgul.ac.uk/id/eprint/110302
Publisher's version: https://doi.org/10.1161/CIRCULATIONAHA.118.031373

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