What do you tell:
A 52 yo F w/ active smoking, DM, HLD, and HTN
who p/w DOE & chest pain with evening walks
whose LHC is negative for stenoses,
& CXR, PFTs, TTE are all unrevealing?
"Don’t worry, you'll be fine…here's a xanaz", right?
🚫WRONG….let's dig deeper. #tweetorial
A 52 yo F w/ active smoking, DM, HLD, and HTN
who p/w DOE & chest pain with evening walks
whose LHC is negative for stenoses,
& CXR, PFTs, TTE are all unrevealing?
"Don’t worry, you'll be fine…here's a xanaz", right?
🚫WRONG….let's dig deeper. #tweetorial
2/13
What's the next step to evaluate her classic angina?
What's the next step to evaluate her classic angina?
3/13
Running behind on a busy clinic...why dig deeper⁉️
👀Well, coronary angiography only "sees" a tiny portion of the coronary tree.
🫀Beyond the epicardial horizon, there's a vast network of pre-arterioles, arterioles, and capillaries.
jacc.org/doi/full/10.10…
Running behind on a busy clinic...why dig deeper⁉️
👀Well, coronary angiography only "sees" a tiny portion of the coronary tree.
🫀Beyond the epicardial horizon, there's a vast network of pre-arterioles, arterioles, and capillaries.
jacc.org/doi/full/10.10…
4/13
Coronary Microvascular Disease (CMD) = disease of these smaller vessels.
Normally, small resistance vessels regulate blood flow.
Abnormalities in these compromise blood flow:
📛Structural
📛Functional
📛Extravascular
jacc.org/doi/full/10.10…
ahajournals.org/doi/10.1161/CI…
Coronary Microvascular Disease (CMD) = disease of these smaller vessels.
Normally, small resistance vessels regulate blood flow.
Abnormalities in these compromise blood flow:
📛Structural
📛Functional
📛Extravascular
jacc.org/doi/full/10.10…
ahajournals.org/doi/10.1161/CI…
5/13
Ok, I get it. Coronary angio's can't see the vast majority of the coronary tree and CMD can exist without epicardial CAD.
🤷But why is this so important❓
Because: CMD w/o obstructive epicardial CAD --> a/w
💔4x mortality
💔5x MACE
ahajournals.org/doi/epub/10.11…
Ok, I get it. Coronary angio's can't see the vast majority of the coronary tree and CMD can exist without epicardial CAD.
🤷But why is this so important❓
Because: CMD w/o obstructive epicardial CAD --> a/w
💔4x mortality
💔5x MACE
ahajournals.org/doi/epub/10.11…
6/13
Fine, CMD is important to look for, but how if we can't see these vessels?
There are invasive and noninvasive tools.
In all of these, look at flow (velocity or tissue perfusion) at rest and stress.
Stress / Rest = cor flow reserve (CFR) = evaluates entire coronary tree.
Fine, CMD is important to look for, but how if we can't see these vessels?
There are invasive and noninvasive tools.
In all of these, look at flow (velocity or tissue perfusion) at rest and stress.
Stress / Rest = cor flow reserve (CFR) = evaluates entire coronary tree.
7/13
PET with absolute myocardial blood flow is most well studied for evaluation of CMD.
Measure absolute myocardial blood flow (MBF) at rest and stress.
MBF@stress / MBF@rest = CFR
PET with absolute myocardial blood flow is most well studied for evaluation of CMD.
Measure absolute myocardial blood flow (MBF) at rest and stress.
MBF@stress / MBF@rest = CFR
8/13
Let’s get back to our patient with chest pain, risk factors, and a negative cath.
FIRST, reassess the pre-test prob (PTP) of coronary disease.
Neg LHC & low PTP --> likely true negative
Neg LHC & high PTP --> likely false negative --> dig deeper!
academic.oup.com/eurheartj/arti…
Let’s get back to our patient with chest pain, risk factors, and a negative cath.
FIRST, reassess the pre-test prob (PTP) of coronary disease.
Neg LHC & low PTP --> likely true negative
Neg LHC & high PTP --> likely false negative --> dig deeper!
academic.oup.com/eurheartj/arti…
9/13
Despite a negative LHC, our patient still has a significant pre-test prob.
🌟Pearl: women are more likely to have coronary microvascular disease.
So: let's dig deeper for coronary microvascular disease!
academic.oup.com/eurheartj/arti…
Despite a negative LHC, our patient still has a significant pre-test prob.
🌟Pearl: women are more likely to have coronary microvascular disease.
So: let's dig deeper for coronary microvascular disease!
academic.oup.com/eurheartj/arti…
10/13
You get a rest/stress PET and…
…the global CFR is 0.88, far less than the diagnostic threshold of 2.
This can be from any combination of epicardial & microvasc CAD.
But for her, with negative LHC and low CFR, we've diagnosed CMD!
What’s the treatment?
You get a rest/stress PET and…
…the global CFR is 0.88, far less than the diagnostic threshold of 2.
This can be from any combination of epicardial & microvasc CAD.
But for her, with negative LHC and low CFR, we've diagnosed CMD!
What’s the treatment?
11/13
Treatment for CMD is less well defined & challenging due to heterogenous causes!
We need more studies!
💊Manage risk factors
💊Aspirin
💊Statin
💊Anti-anginals for sx
💊Rx associated conditions (?infiltrative CM)
💊Stay tuned for novel therapies
Treatment for CMD is less well defined & challenging due to heterogenous causes!
We need more studies!
💊Manage risk factors
💊Aspirin
💊Statin
💊Anti-anginals for sx
💊Rx associated conditions (?infiltrative CM)
💊Stay tuned for novel therapies
12/13
Summary:
💙LHC misses the majority of coronary vessels
💜CMD carries an adverse prognosis
💚You won't know if you won't look
🧡Management remains unclear
💔Prognosis is NOT benign
❤️Emphasize Prevention: cardionerds.com/episodes/cardi…
Summary:
💙LHC misses the majority of coronary vessels
💜CMD carries an adverse prognosis
💚You won't know if you won't look
🧡Management remains unclear
💔Prognosis is NOT benign
❤️Emphasize Prevention: cardionerds.com/episodes/cardi…
13/13
🧠Here's a mind twister:
If a patient has classic angina with risk factors, a positive stress test, and a negative cath:
❓Is the stress test a false (+)
❓Or is the Cath a false (-)?
Don't forget to look for CMD!
🧠Here's a mind twister:
If a patient has classic angina with risk factors, a positive stress test, and a negative cath:
❓Is the stress test a false (+)
❓Or is the Cath a false (-)?
Don't forget to look for CMD!
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