Non-invasive measures of coronary microcirculation: Taking the long road to the clinic
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Cardiology Section, Veterans Affairs Palo Alto Health Care Administration, Palo Alto, CA Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
Received Jun 15, 2017; accepted Jun 16, 2017 doi:10.1007/s12350-017-0972-2
Although coronary microvascular disease is now a well-recognized entity that is associated with significant morbidity and mortality, current non-invasive strategies cannot differentiate between coronary microvascular disease (CMD) and obstructive epicardial stenosis. While the evaluation of intramyocardial blood volume as a surrogate measure for microvascular health may have limited sensitivity in early-stage disease, this strategy does enable the diagnosis of CMD in the presence of concurrent epicardial disease, bringing us one step further toward improving the management of this disease. Herein, we discuss the advantages and limitations of current non-invasive measures of CMD and the need for further investment in bringing these technologies to the bedside. Key Words: Coronary microcirculation Æ myocardial perfusion imaging: SPECT Æ coronary artery disease Æ coronary blood flow Æ PET/CT imaging Æ diagnostic and prognostic application
See related article, doi: 10.1007/s12350017-0970-4. Atherosclerotic plaque can develop in the large epicardial arteries, leading to the development of ischemic heart disease (IHD), a major cause of death worldwide.1 Although the diagnosis and treatment of epicardial coronary stenosis remain the primary focus of IHD management, patients with IHD may also have concurrent damage to the inner lining of the tiny coronary arteries that constitute the coronary microcirculation, resulting in spasm and decreased myocardial blood flow.2-4 Recent studies have shown that patients who have coronary microvascular disease (CMD) with and without significant obstructive epicardial disease are Reprint requests: Patricia K. Nguyen, Division of Cardiovascular Medicine, Department of Medicine, Stanford University, 300 Pasteur Drive, Grant Building S114, CA 94301; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2017 American Society of Nuclear Cardiology.
at increased risk for cardiac-related morbidity and mortality.5,6 Due to the lack of robust and accurate noninvasive measures to evaluate CMD in the presence of concurrent epicardial stenosis, CMD remains an underdiagnosed and under-treated disease.7 Because of the need for exquisite spatial resolution to visualize this tiny complex vascular network, available invasive and non-invasive strategies cannot directly evaluate the human coronary microcirculation in vivo. Instead, these techniques indirectly measure parameters that are dependent on the functional integrity of the microcirculation. Several invasive (e.g., Dopplerderived coronary flow reserve and index of microcirculatory resistance) and non-invasive strategies (e.g., myocardial flow reserve by PET, Echo, and MRI)8-11 have been employed to study the coronary microcirculation. Compared to non-invasive strategies, the majo
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