To the editor
I read with interest the excellent Contemporary Review in Cardiovascular Medicine on primary coronary microvascular dysfunction by Lanza and Crea.1 In their review, the authors discuss the diagnosis of coronary microvascular dysfunction and state that invasive assessment of the microvasculature at the time of coronary angiography is complex, time-consuming, and adds unjustified risk. Emerging data suggest that the measurement of fractional flow reserve (FFR), coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR) with a pressure or flow sensor tipped coronary wire can be performed easily, safely and quickly and can provide important diagnostic and prognostic information, which may not be obtained noninvasively.2,3 By interrogating the epicardial coronary vessels with FFR, it is possible to identify and to treat appropriately an important subset of patients with diffuse epicardial atherosclerosis who have angiographically normal appearing vessels but are often mistakenly given the diagnosis of coronary microvascular dysfunction.4 Simultaneous determination of a newer index, IMR, assesses the status of the microvasculature independent of both epicardial coronary artery stenosis and of changes in hemodynamics, something that is not be possible with measurement of coronary flow reserve, whether performed invasively or noninvasively.5 Thus, using a coronary wire-based method, patients with chest pain and angiographically normal appearing coronary arteries can receive a safe, efficient and accurate diagnosis.
Footnotes
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Conflict of Interest Disclosures: None
References
- 1.Lanza GA, Crea F. Primary coronary microvascular dysfunction clinical presentation, pathophysiology, and management. Circulation. 2010;121:2317–2325. doi: 10.1161/CIRCULATIONAHA.109.900191. [DOI] [PubMed] [Google Scholar]
- 2.Kern MJ, Lerman A, Bech JW, De Bruyne B, Eeckhout E, Fearon WF, Higano ST, Lim MJ, Meuwissen M, Piek JJ, Pijls NH, Siebes M, Spaan JA. Physiological assessment of coronary artery disease in the cardiac catheterization laboratory: a scientific statement from the American Heart Association committee on diagnostic and interventional cardiac catheterization, council on clinical cardiology. Circulation. 2006;114:1321–41. doi: 10.1161/CIRCULATIONAHA.106.177276. [DOI] [PubMed] [Google Scholar]
- 3.Pepine CJ, Anderson RD, Sharaf BL, Reis SE, Smith KM, Handberg EM, Johnson BD, Sopko G, Bairey Merz CN. Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE (Women's Ischemia Syndrome Evaluation) study. J Am Coll Cardiol. 2010;55:2825–32. doi: 10.1016/j.jacc.2010.01.054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.De Bruyne B, Hersbach F, Pijls NHJ, Bartunek J, Bech JW, Heyndrickx GR, Gould KL, Wijns W. Abnormal epicardial coronary resistance in patients with diffuse atherosclerosis but normal coronary angiography. Circulation. 2001;104:2401–06. doi: 10.1161/hc4501.099316. [DOI] [PubMed] [Google Scholar]
- 5.Ng MK, Yeung AC, Fearon WF. Invasive assessment of the coronary microcirculation: superior reproducibility and less hemodynamic dependence of index of microcirculatory resistance as compared to coronary flow reserve. Circulation. 2006;113:2054–61. doi: 10.1161/CIRCULATIONAHA.105.603522. [DOI] [PubMed] [Google Scholar]