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  • Review Article
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Coronary microvascular dysfunction: mechanisms and functional assessment

Nature Reviews Cardiology volume 12, pages 48–62 (2015)Cite this article

Subjects

Key Points

  • Prearterioles (100–500 μm in diameter) and arterioles (<100 μm in diameter, the site of metabolic regulation of myocardial blood flow) make up the coronary microcirculation

  • In the past 2 decades, coronary microvascular dysfunction emerged as an important mechanism of myocardial ischaemia

  • Coronary microvascular dysfunction can result from functional and/or structural alterations, the relative importance of which seems to vary across clinical settings; several such alterations can also coexist in one condition

  • No technique can visualize the coronary microcirculation in vivo in humans; microvascular function is, therefore, assessed indirectly, through measurements of coronary or myocardial blood flow and coronary flow reserve

  • Several invasive and noninvasive techniques can be used to assess microvascular function, including intracoronary Doppler flow velocity wires, PET, and cardiac MRI

Abstract

Obstructive disease of the epicardial coronary arteries was recognized as the cause of angina pectoris >2 centuries ago, and sudden thrombotic occlusion of an epicardial coronary artery has been established as the cause of acute myocardial infarction for >100 years. In the past 2 decades, dysfunction of the coronary microvasculature emerged as an additional mechanism of myocardial ischaemia that bears important prognostic implications. The coronary microvasculature (vessels <300 μm in diameter) cannot be directly imaged in vivo, but a number of invasive and noninvasive techniques, each with relative advantages and pitfalls, can be used to assess parameters that depend directly on coronary microvascular function. These methods include invasive or noninvasive measurement of Doppler-derived coronary blood flow velocity reserve, assessment of myocardial blood flow and flow reserve using noninvasive imaging, and calculation of microcirculatory resistance indexes during coronary catheterization. These advanced techniques for assessment of the coronary microvasculature have provided novel insights into the pathophysiological role of coronary microvascular dysfunction in the development of myocardial ischaemia in different clinical conditions.

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Figure 1: Coronary arterial circulation.
Figure 2: Remodelling of coronary arterioles is associated with coronary microvascular dysfunction.
Figure 3: Coronary microvascular dysfunction can result from a variable combination of abnormal vasodilatation (owing to endothelium-dependent and endothelium-independent mechanisms) and increased vasoconstriction caused by various stimuli.
Figure 4: Coronary microvascular dysfunction can result from abnormal extravascular pressure.
Figure 5: Blood and tissue input functions for calculation of myocardial blood flow using PET and cardiac MRI.
Figure 6: Reverse coronary arteriolar remodelling after treatment in arterial hypertension.
Figure 7: Microvascular obstruction.
Figure 8: Coronary flow velocity reserve after acute infarction predicts mortality at follow-up.

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Acknowledgements

The authors thank Dr E. Barbato (Cardiovascular Research Center, Aalst, Belgium) for helpful discussions of methods for invasive measurement of myocardial blood flow and coronary flow reserve.

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Authors and Affiliations

  1. Vita Salute University and Scientific Institute San Raffaele, Via Olgettina, 58, Milano, 20132, Italy

    Paolo G. Camici

  2. Department of Radiology, Oncology and Pathology, “Sapienza” Università di Roma, Policlinico Umberto I, Viale Regina Elena, 324, Rome, 00161, Italy

    Giulia d'Amati

  3. CNR IBFM, Via Fratelli Cervi, 93, Segrate (MI), 20090, Italy

    Ornella Rimoldi

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  1. Paolo G. Camici
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O.R. researched the data for the article, and O.R. and P.G.C. discussed the content. All the authors participated in writing, reviewing, and editing of the manuscript before submission.

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Correspondence to Ornella Rimoldi.

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P.G.C. declares that he has acted as a consultant for Servier International. The other authors declare no competing interests.

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Camici, P., d'Amati, G. & Rimoldi, O. Coronary microvascular dysfunction: mechanisms and functional assessment. Nat Rev Cardiol 12, 48–62 (2015). https://doi.org/10.1038/nrcardio.2014.160

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