Alejandro González Veliz: Looking Beyond Coronary Anatomy to Understand Ischemia
Alejandro González Veliz, Interventional Cardiologist at Institute of Cardiology and Cardiovascular Surgery, shared a post on LinkedIn:
“Normal coronary angiography does not always mean normal coronary physiology.
Patients may experience persistent angina, dyspnea, or evidence of myocardial ischemia despite the absence of significant obstructive coronary artery disease. One potential explanation is coronary microvascular dysfunction (CMD), an important mechanism within the spectrum of Ischaemia with Non-Obstructive Coronary Arteries (INOCA).
How can we investigate what angiography cannot reveal?
Two key physiological parameters help characterize coronary microvascular function:
- Index of Microcirculatory Resistance (IMR): Assesses coronary microvascular resistance during maximal hyperemia. With standard bolus thermodilution, an IMR greater than or equals to 25 units suggests increased microvascular resistance.
- Coronary Flow Reserve (CFR): Measures the capacity to augment coronary blood flow during hyperemia compared with resting flow. Reduced CFR may reflect impaired vasodilatory capacity, although it can also be influenced by elevated resting flow or epicardial coronary disease.
IMR and CFR provide complementary information. Neither should be interpreted in isolation, and acetylcholine testing may be necessary to identify epicardial or microvascular vasospasm.
The 2024 ESC Guidelines for chronic coronary syndromes emphasize the importance of evaluating patients with suspected ANOCA/INOCA. In appropriately selected patients with persistent symptoms despite non-obstructive coronary arteries, invasive coronary function testing can help identify the underlying endotype and guide individualized treatment.
The CorMicA trial demonstrated improvements in angina and quality of life with treatment guided by invasive coronary function testing, although it was not powered to establish a reduction in major cardiovascular events.
The take-home message: Angiography defines coronary anatomy, but it does not fully characterize coronary physiology. When symptoms persist despite the absence of significant epicardial obstruction, the diagnostic process should not necessarily end with a “normal” angiogram.
Clinical question: In patients with persistent angina and non-obstructive coronary arteries, do you routinely consider coronary function testing?”
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