The Present and Future
JACC State-of-the-Art Review
Coronary Microvascular Disease Pathogenic Mechanisms and Therapeutic Options: JACC State-of-the-Art Review

https://doi.org/10.1016/j.jacc.2018.09.042Get rights and content
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Abstract

Coronary microvascular disease (CMD) refers to the subset of disorders affecting the structure and function of the coronary microcirculation, is prevalent in patients across a broad spectrum of cardiovascular risk factors, and is associated with an increased risk of adverse events. Contemporary evidence supports that most patients with CMD also have macrovessel atherosclerosis, which has important implications for their prognosis and management. In this state-of-the-art review, the authors summarize the pathophysiology of CMD, provide an update of diagnostic testing strategies, and classify CMD into phenotypes according to severity and coexistence with atherosclerosis. They examine emerging data highlighting the significance of CMD in specific populations, including obesity and insulin resistance, myocardial injury and heart failure with preserved ejection fraction, and nonobstructive and obstructive coronary artery disease. Finally, they discuss the role of CMD as a potential target for novel interventions beyond conventional approaches, representing a new frontier in cardiovascular disease reduction.

Key Words

coronary flow reserve
coronary microvascular dysfunction
heart failure with preserved ejection fraction
ischemic heart disease
nonobstructive coronary artery disease

Abbreviations and Acronyms

CFR
coronary flow reserve
CKD
chronic kidney disease
CMD
coronary microvascular disease
CT
computed tomography
HFpEF
heart failure with preserved ejection fraction
IHD
ischemic heart disease
LV
left ventricular
MACE
major adverse cardiovascular events
MI
myocardial infarction
PET
positron emission tomography

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This work was supported by K23HL135438 to Dr. Taqueti and R01HL132021 to Dr. Di Carli. Dr. Di Carli has received consulting fees from Sanofi and General Electric; and has received a research grant from Spectrum Dynamics.

Listen to this manuscript's audio summary by JACC Editor-in-Chief Dr. Valentin Fuster.