Microvascular angina

Capri 2016
Disfunzione del microcircolo coronarico
nella cardiopatia ischemica
Filippo Crea
Institute of Cardiology
Catholic University of the Sacred Heart
Rome, Italy
Type 1 CMD
• Microvascular angina (MVA)
• Myocardial infarction with no
obstructive atherosclerosis
Type 1 CMD
• Microvascular angina (MVA)
• Myocardial infarction with no
obstructive atherosclerosis
Microvascular angina
• Angina
• Evidence of ischemia
• No obstructive CAD
• No epicardial coronary spasm
Prevalence of obstructive CAD in relation to symptoms and
non invasive testing in patients undergoing selective
coronary angiography (n=398,978)
(Patel et al, NEJM 2010)
SA in women with NCA is associated with higher
risk of MACEs (n=4,711)
(Prescott et al, EHJ 2011)
Mechanisms of MVA
• Enhanced response to vasoconstrictor stimuli
• Impairment of endothelium-dependent and
independent vasodilation
• Enhanced pain perception
(Lanza & Crea, Circulation 2010)
A-ch-induced microvascular spasm
indicates enhanced microvascular
susceptibilty to constrictor stimuli
A-ch
Nitrates
(Ong et al, JACC 2012)
Baseline
Dipyridamole
Type 1 CMD
• Microvascular angina (MVA)
• Myocardial infarction with no
obstructive atherosclerosis
Prevalence
of MINOCA
(Pasupathy et al,
Circulation 2015)
All-cause mortality in patients with
MINOCA or MI-CAD
(Pasupathy et al, Circulation 2015)
AMI according to Universal definition
Consider AMI due to increased MVO2
Consider AMI due to non cardiac causes
Coronary angiography
LV angiogram
Normal o regional wall motion
abnormatilies with
“epicardial pattern”
Normal o regional wall motion
abnormalities without
“epicardial pattern”
Epicardic causes
Microvascular causes
Suspected
fissure or
dissection
Suspected
epicardial spasm
Provocative test
(ergonovine/Ach)
IVUS/OCT
CMR with
CM
Confirmed
myocarditis
(Niccoli & Crea, EHJ 2015)
Suspected
microvascular
spasm
Suspected TTC or
myocarditis
EBM
Provocative
test (ACh)
Suspected
microembolism
TEE, CEE
Type 3 CMD
• Stable angina
• CMVO after primary PCI
Type 3 CMD
• Stable angina
• CMVO after primary PCI
OMT vs OMT + stenting in patients with
SA and documented myocardial ischemia
(n=5286)
Death
Non fatal MI
Unplanned revasculariazation
Persistent angina
(Stergiopoulos et al, JAMA 2014)
CMD after elective PCI: correlation with exercise
stress test results (n=29, positive EST=11)
(Milo et al, Int J Cardiol 2013)
Type 3 CMD
• Stable angina
• CMVO after primary PCI
Microvascular obstruction in man
Individual susceptibility
Distal
embolization
Reperfusion
injury
Ischemic
Injury
(Niccoli et al. JACC 2009)
Outcome of CMVO
MACE
DEATH
RE-AMI
HF
(Hamirani et al, JACC Int 2014)
MI after PCI: a meta-analysis of
troponin elevation (29%) (n=7578)
MACEs
All cause death
(Testa et al, QJM 2009)