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Coronary microvascular dysfunction — Clinical Guidelines

Overview

Coronary microvascular dysfunction (CMD) is a significant cause of angina, characterized by impaired function of the small coronary arteries, often leading to myocardial ischemia despite normal epicardial coronary arteries 1.

Diagnosis

Key Diagnostic Criteria: Documented CMD using methods such as intracoronary Doppler wire, thermodilution techniques, or perfusion imaging via PET/MRI 1.

Recommended Tests: Coronary flow reserve (CFR) < 2.5, myocardial perfusion reserve (MPR) < 2.5, and/or index of microvascular resistance (IMR) > 25 1.

Grading: Methodological quality assessed via the Cochrane Risk of Bias tool 1.

Management

First-Line Treatments: Limited evidence-based options; specific drug classes and doses not extensively detailed in current literature 1.

Adjunctive Treatments: Further research needed; some treatments explored but not definitively recommended 1.

Vitamin D Considerations: Deficiency may impair endothelial function and vascular eNOS expression; calcitriol supplementation showed mixed results in animal models 3.

Special Populations

Pregnancy: Not specifically addressed in provided abstracts.

Pediatrics: Not specifically addressed in provided abstracts.

Elderly: Not specifically addressed in provided abstracts.

Comorbidities: Metabolic derangements (e.g., diabetes, high-fat diet) are risk factors and can be studied using animal models 4.

Key Recommendations

Use stringent diagnostic criteria for CMD, including CFR, MPR, and IMR measurements via advanced imaging techniques (Evidence: Strong 1).

Consider the role of metabolic derangements in CMD pathogenesis and utilize appropriate animal models for research (Evidence: Moderate 4).

Further investigate vitamin D status and supplementation as potential adjunctive therapies, acknowledging mixed outcomes in preliminary studies (Evidence: Weak 3).

References

1 Khandkar C, Rehan R, Ravindran J, Yong A. An updated review on therapeutic strategies in coronary microvascular dysfunction. International journal of cardiology 2025. link 2 Kissane RWP, Al-Shammari AA, Egginton S. The importance of capillary distribution in supporting muscle function, building on Krogh's seminal ideas. Comparative biochemistry and physiology. Part A, Molecular & integrative physiology 2021. link 3 Wee CL, Mokhtar SS, Banga Singh KK, Rasool AHG. Vitamin D deficiency attenuates endothelial function by reducing antioxidant activity and vascular eNOS expression in the rat microcirculation. Microvascular research 2021. link 4 Sorop O, van de Wouw J, Chandler S, Ohanyan V, Tune JD, Chilian WM et al.. Experimental animal models of coronary microvascular dysfunction. Cardiovascular research 2020. link 5 Schoeff S, Hernandez B, Robinson DJ, Jameson MJ, Shonka DC. Microvascular anastomosis simulation using a chicken thigh model: Interval versus massed training. The Laryngoscope 2017. link 6 Feng AL, Razavi CR, Lakshminarayanan P, Ashai Z, Olds K, Balicki M et al.. The robotic ENT microsurgery system: A novel robotic platform for microvascular surgery. The Laryngoscope 2017. link 7 Ilsar R, Chawantanpipat C, Chan KH, Dobbins TA, Waugh R, Hennessy A et al.. Measurement of pulmonary flow reserve and pulmonary index of microcirculatory resistance for detection of pulmonary microvascular obstruction. PloS one 2010. link 8 Alsip NL, Hornung JW, Saha PR, Hill JB, Asher EF. A new technique for studying the uterine microvasculature in the rat. American journal of obstetrics and gynecology 1996. link70151-5)

Coronary microvascular dysfunction