Table 1.
Timeline of coronary microvascular disease onset, progression to heart failure with preserved ejection fraction, and therapy
| Time | Visit type | Symptoms | Medications | Vital signs | Laboratory assessments | Diagnostic testing |
|---|---|---|---|---|---|---|
| December 2006 (baseline) | Initial evaluation for symptoms of ischemic heart disease | 5-month history of dyspnea both at rest and at exertion, squeezing chest pain on a daily basis, intermittent palpitations | Lipitor (atorvastatin; 20 mg, daily), lisinopril (20 mg, daily), aspirin (81 mg, daily) and sublingual nitroglycerin (0.4 mg, as needed) | Blood pressure, 120/75 mmHg; pulse, 60 bpm |
Sodium, 143 (reference range, 135–145 mmol/L); potassium, 3.8 (reference range, 3.5–5.0 mmol/L), creatinine, 0.5 (0.6–1.1 mg/dL) |
Diagnostic coronary reactivity testing demonstrating coronary endothelial dysfunction. Previous right left heart catheterization showed normal coronary arteries and was negative for any shunt. CMRI showed normal left ventricular structure and function. MPRI borderline normal 1.8 |
| November 2016 (10-year follow-up) | Emergency Department visit for heart failure and initial diagnosis for heart failure with preserved ejection fraction | Increased orthopnea, dyspnea, mild diffuse headache, lower extremity edema, and elevated blood pressure | Eplerenone (25 mg, daily), lisinopril (40 mg, daily), aspirin (81 mg, daily), pravastatin (40 mg, daily), spironolactone (100 mg, daily), nitroglycerin (0.4 mg, as needed) | Blood pressure, 152/77 mmHg; pulse, 70 bpm; respiratory rate, 18; temperature, 36.9 °C (98.4 °F) |
BNP, 406 (reference range, < 100 pg/mL); troponin, < 0.01 (reference range, < 0.04 ng/mL); hemoglobin, 9.9 (reference range, 10.6–13.5 g/dL); sodium, 139 (reference range, 135–145 mmol/L); potassium, 4.3 (reference range, 3.5–5.0 mmol/L); creatinine, 0.5 (0.6–1.1 mg/dL) |
Follow-up CMRI revealed worsening ischemia with MPRI 1.1 and increased wall thickness, with evidence of myocardial steatosis |
bpm beats per minute, BNP brain natriuretic peptide, CMRI cardiac magnetic resonance imaging, MPRI myocardial perfusion reserve index