Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial...

10
12/16/16 1 Coronary Microvascular Disease: Does It Exist? EA Amsterdam, MD Distinguished Professor Cardiology and Internal Medicine UC Davis School of Medicine and Medical Center Sacramento, CA 63 yo woman with chest pain Exertional CP 3-4x/wk, +/- response to meds Normal baseline ECG. Pos ETT, Neg ESE Several visits to ED with CP Nonspecific ST-T during CP, negative troponins 1 Admission: Neg eval for ACS Coronary angio: 10-20% stenoses in LAD/RCA, LVEF 60% ………………………………………………………………………………. On multiple antianginal meds, RF reduction GI, pulmonary, musculoskeletal w/u NEG. Counseling for psychosocial stress Coronary Microcirculation Classification Anatomy/Physiology Clinical Assessment of coronary microcirculation Prognosis Management Coronary Microcirculation Classification Anatomy/Physiology Clinical Assessment of coronary microcirculation Prognosis Management

Transcript of Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial...

Page 1: Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial dysfunction SMC dysfunction Vascular remodeling Pathogenetic Mechanisms Type 2 myocardial

12/16/16

1

CoronaryMicrovascularDisease:DoesItExist?

EAAmsterdam,MDDistinguishedProfessorCardiologyandInternalMedicineUCDavisSchoolofMedicineandMedicalCenterSacramento,CA

63yo womanwithchestpain• ExertionalCP3-4x/wk,+/- responsetomeds• NormalbaselineECG.Pos ETT,Neg ESE• SeveralvisitstoEDwithCP

– NonspecificST-TduringCP,negativetroponins

• 1Admission:Neg eval forACS– Coronaryangio:10-20%stenoses inLAD/RCA,LVEF60%……………………………………………………………………………….

• Onmultipleantianginalmeds,RFreduction• GI,pulmonary,musculoskeletalw/uNEG.Counselingforpsychosocialstress

CoronaryMicrocirculation

• Classification• Anatomy/Physiology• Clinical• Assessmentofcoronarymicrocirculation• Prognosis• Management

CoronaryMicrocirculation

• Classification• Anatomy/Physiology• Clinical• Assessmentofcoronarymicrocirculation• Prognosis• Management

Page 2: Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial dysfunction SMC dysfunction Vascular remodeling Pathogenetic Mechanisms Type 2 myocardial

12/16/16

2

TermsAppliedtoSyndromeofChestPainwithoutObstructiveCAD

• CardiacsyndromeX• Coronarymicrovasculardysfunction(CMD)• Microvascularangina• Endothelialdysfunction• Impairedcoronaryvasodilatorcapacity• Impairedcoronaryflowreserve• ………………………………………………………………• Abnormalpainperception(“sensitiveheart”)• Somatoformdisorder

TR

Clinical Setting

ClassificationofCoronaryMicrovascularDysfunction

TYPE 1 absence of myocardial disease and obstructive CAD

Risk factors Microvascular angina

Endothelial dysfunction SMC dysfunction Vascular remodeling

PathogeneticMechanisms

Type 2 myocardial diseases HCM,DCM,amyloid

Stable CAD, ACSType 3 obstructive CAD

Type 4 iatrogenic PCI,CABG

Vascular remodelingEndothelial dysfunctionSmooth muscle dysfunctionAutonomic dysfunctionImpaired arteriolar function

TypeofMVD

F.Crea etal. EuropeanHeartJournal2014;35,1101–1111

TR

Clinical Setting

ClassificationofCoronaryMicrovascularDysfunction

TYPE 1 absence of myocardial disease and obstructive CAD

Risk factors Microvascular angina

• Endothelial dysfunction • SMC dysfunction • Vascular remodeling• Impaired arteriolar fxn

PathogeneticMechanisms

Type 2 myocardial diseases HCM,DCM,amyloid

Stable CAD, ACSType 3 obstructive CAD

Type 4 iatrogenic PCI,CABG

Vascular remodelingEndothelial dysfunctionSmooth muscle dysfunctionAutonomic dysfunctionImpaired arteriolar function

TypeofMVD

F.Crea etal. EuropeanHeartJournal2014;35,1101–1111

F.Crea etal. EuropeanHeartJournal2014;35,1101–1111

ClassificationofCoronaryMicrovascularDysfunction

Page 3: Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial dysfunction SMC dysfunction Vascular remodeling Pathogenetic Mechanisms Type 2 myocardial

12/16/16

3

CoronaryMicrocirculation

• Classification• Anatomy/Physiology• Clinical• Assessmentofcoronarymicrocirculation• Prognosis• Management

CoronaryArteriesandArterioles

RCA

Page 4: Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial dysfunction SMC dysfunction Vascular remodeling Pathogenetic Mechanisms Type 2 myocardial

12/16/16

4

RCA

BLUSH

CoronaryArterySizeandDistribution

CoronaryArteryPhysiology:Endothelium-Derived/OtherVasoactiveAgents

The coronary arterioles are normally in a relatively dilated state

Adenosine

VASCULARLUMEN

CoronaryArteryPhysiology:Endothelium-Derived/OtherVasoactiveAgents

The coronary arterioles are normally in a relatively dilated state

Adenosine

VASCULARLUMEN

Page 5: Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial dysfunction SMC dysfunction Vascular remodeling Pathogenetic Mechanisms Type 2 myocardial

12/16/16

5

CoronaryMicrocirculation

• Classification• Anatomy/Physiology• Clinical• Assessmentofcoronarymicrocirculation• Prognosis• Management

CMD– Demographics

–20-30%ofpatientswithanginal-typeCPhavenoobstructiveCAD(normalor<50%stenosis)• Usuallyhaveobjectiveevidenceofischemia

–Women:~3-5Xmorefrequentthaninmen

–ExcludeotheretiologiesofCP• Coronaryspasm,myocardialbridging,pericarditis,GI/Pul/MS/Psychosocialstress…

ClinicalPresentation- CMD– Allpts

• CPandnonobstructive orNLcoronaryarteries• ButbroadcontinuumofSx,RFs,ischemiatestresults

– GroupA)Typicalangina,+RFs,ischemiaonnoninvasivetests• ETT,stressimaging,AmbulatoryECG

– GroupB) AtypicalCP,+/- RFs,+/- ischemiastresstests

– GroupC)VariabledatafromgroupsAandB• Sx,RFs,Tests

ExerciseTreadmill

Page 6: Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial dysfunction SMC dysfunction Vascular remodeling Pathogenetic Mechanisms Type 2 myocardial

12/16/16

6

ExerciseTreadmill

7min

CoronaryMicrocirculation

• Classification• Anatomy/Physiology• Clinical• Assessmentofcoronarymicrocirculation• Prognosis• Management

ImpressionofCoronaryMicrocirculationbyMyocardialBlush

ImpressionofCoronaryMicrocirculationbyMyocardialBlush

Page 7: Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial dysfunction SMC dysfunction Vascular remodeling Pathogenetic Mechanisms Type 2 myocardial

12/16/16

7

ThePhysiologic“Angiogram”

• IntracoronaryAcetylcholine– Testsintegrityofmicrovascularendothelium– Normal:increaseCBF>50%abovecontrol

• IntracoronaryAdenosine– Testsdirectresponseofmicrovasculardilatation– Normal:increaseinCBF≥2.5Xovercontrol

ImagingMethods

• PositronEmissionTomography(PET)Rubidium– Imagestransmyocardial distributionofCBF,detectsimpairedriseinsubendocardial CBFindicativeofCMD

• CardiacMRI– Detectsinadequatesubendocardial distributionofCBF,therebyidentifyingCMDbyinadequateincreaseinresponsetostress(adenosine)

Copyright ©2012 American College of Cardiology Foundation. Restrictions may apply.

Murthy, JACC 2012;59:E1373

Coronary Microvascular Function in Patients with Suspected CAD: Relation to Gender

307 women, 97 men

Frequency/magnitude of coronary microvascular dysfunction are similar in both genders

Page 8: Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial dysfunction SMC dysfunction Vascular remodeling Pathogenetic Mechanisms Type 2 myocardial

12/16/16

8

Reducedsubendocardial perfusionprovidingevidenceforcoronaryMVD

CardiacSyndromeXNEJM2002;346:1948

STRESS-INDUCEDMICROVASCULARISCHEMIA

BermanetaL. JACC4/16

NormalstressperfusionMRI

Uniformcontrastenhancementoflvmyocardium

Page 9: Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial dysfunction SMC dysfunction Vascular remodeling Pathogenetic Mechanisms Type 2 myocardial

12/16/16

9

41yo runnerwithchestpainandnormalcoronaryangio

ReducedsubendocardialenhancementduringGadoliniuminfusion(darkarea,arrow)

• StressperfusionMRIwithGadoliniunm

CoronaryMicrocirculation

• Classification• Anatomy/Physiology• Clinical• Assessmentofcoronarymicrocirculation• Prognosis• Management

Prognosis• Initiallyfelttoberelativelybenign• Recentfindings:CMDassociatedwithadverseclinicaloutcomes(Murthy,Circ 2014,129:2518)

• CFR<2.0,n=641pts,61yo,1.3yr interval– 8.6%MACE,5%mortality

• CMD:Prevalence/outcomessimilarinthesexes

CoronaryMicrocirculation

• Classification• Anatomy/Physiology• Clinical• Assessmentofcoronarymicrocirculation• Prognosis• Management

Page 10: Exertional CP Coronary Microvascular Disease: Does It Exist? · Microvascular angina Endothelial dysfunction SMC dysfunction Vascular remodeling Pathogenetic Mechanisms Type 2 myocardial

12/16/16

10

Management• Antianginalmeds (incl.ranolazione),Riskfactormodification• Statins,ACEI/ARB

– Enhancedendothelialfunction

• CardiacRehab– Comprehensive,exercise-centered

• Hormonereplacementtherapy– Beneficialeffectonendothelium(?),giveforshortestpossibleinterval

..……………………………………………………………………………………………………………..

• Counseling– Psychosocialstressreduction,sx mayberelatedtosomatoformdisorder

• Imipramine– EffectiveinsomeptswithDx sensitiveheart

OurPatient

• MRI:Nostress-inducedsubendocardial ischemia• NoobstructiveCAD,negativestressimagingtests• ConsiderSomatoformDisorderorSensitiveHeart• Imipraminewasaddedtohertherapy.

Copyright ©2012 American College of Cardiology Foundation. Restrictions may apply.

Murthy, JACC 2012;59:E1373

Coronary Microvascular Function in Patients with Suspected CAD: Relation to Gender

307 women, 97 men

Summary• Coronarymicrovasculardisease:real,multipleetiologies,can

occurasisolatedabnormality• Dx requiresrigorousevaluation• MorewomenthanmenwithMVD(butratesimilarinW/M)• Adverseprognosticeffecthasbeendocumented• Diagnostic approach favors MRI or PET rubidium scan• ………………………………………………………………………………………..• Managementnotyetspecific,multipleapproaches• Considersomatoformdisorder,sensitiveheart