Coronary Microvascular Dysfunction.
Coronary Microvascular Dysfunction.
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DOI：
10.3390/jcm9092880
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发表时间：
2020-09-06
影响因子：
3.9
通讯作者：
Henein M
中科院分区：
文献类型：
--
作者：
Vancheri F;Longo G;Vancheri S;Henein M
许多胸痛患者行冠状动脉造影术时未显示明显的阻塞性冠状动脉病变。由于内皮和平滑肌细胞功能障碍，这些患者中有相当一部分具有冠状动脉微循环功能和结构的异常。冠状动脉微循环在响应心脏氧需求的冠状动脉血流调节中具有基本作用。这种机制的损害，定义为冠状动脉微血管功能障碍（CMD），会增加心血管不良临床结局的风险。冠状动脉内皮功能障碍约占三分之二的临床病症，其表现为无阻塞性冠状动脉疾病的心肌缺血症状和体征，称为“缺血伴非阻塞性冠状动脉疾病”（INOCA），以及一小部分“心肌梗死伴非阻塞性冠状动脉疾病”（MINOCA）。更常见的是，INOCA的临床表现是由CMD引起的微血管性心绞痛，而一些患者由于心外膜痉挛而出现血管痉挛性心绞痛，以及心外膜和微血管的混合形式。CMD可能与局灶性和弥漫性心外膜冠状动脉粥样硬化相关，两者可能相互强化。INOCA和MINOCA在女性中更常见。CMD的临床分类包括与其中动脉粥样硬化具有有限相关性的病症、与非阻塞性动脉粥样硬化以及与阻塞性动脉粥样硬化的关联。已有几项研究支持CMD是涉及多个器官（如脑和肾）的全身性微血管疾病的一部分。此外，CMD与射血分数保留的心力衰竭（HFpEF）、糖尿病、高血压性心脏病以及慢性炎症性和自身免疫性疾病的发展密切相关。由于冠状动脉微循环在有创血管造影或计算机断层冠状动脉造影（CTCA）上不可见，因此CMD的诊断通常基于微循环的功能评估，可以通过有创和无创方法进行，包括血管造影期间造影剂延迟流动的评估，冠状动脉血流储备（CFR）和微血管阻力指数（IMR）的测量，评价冠状动脉内乙酰胆碱输注诱导的心绞痛，并通过正电子发射断层扫描（PET）和磁共振（CMR）评估心肌灌注。
Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed “ischemia with non-obstructive coronary artery disease” (INOCA) and for a small proportion of “myocardial infarction with non-obstructive coronary artery disease” (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).
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