Author + information
- Received July 3, 2018
- Accepted July 30, 2018
- Published online November 19, 2018.
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas
- ↵∗Address for correspondence:
Dr. K. Lance Gould, Weatherhead PET Center, McGovern Medical School at UTHealth, 6431 Fannin Street, Room MSB 4.256, Houston, Texas 77030.
Angina with no angiographic stenosis, commonly called “microvascular angina,” encompasses a wide continuum of coronary pathophysiology in conflicting published reports. Comprehensive quantitative myocardial perfusion offers new insights beyond overly simplistic coronary flow reserve. Integrating regional absolute stress flow, relative stress flow, coronary flow reserve, and qualitative subendocardial perfusion gradient on tomograms of relative images, provides correct diagnosis, quantitative physiological classification, and potential treatment. Angina without angiographic stenosis is associated with abnormal quantitative perfusion with rare, but instructive, exceptions. However, microvascular dysfunction without angina is common, particularly associated with risk factors. Reduced subendocardial/epicardial relative activity is common with diffuse coronary artery disease without focal stenosis with or without angina depending on the severity of reduced subendocardial perfusion. Precision quantitative myocardial perfusion in 5,900 cases objectively classifies angina with no angiographic stenosis into 4 categories: subendocardial ischemia due to diffuse coronary artery disease (most common), overlooked stenosis, diffuse microvascular dysfunction due to risk factors or specific microvasculopathies, and nonischemic cardiac pain mechanisms (rare), or some mix of these prototypes, of which 95% associate with risk factors, or subclinical or clinically manifest coronary atherosclerosis needing vigorous risk factor treatment.
Funding was received from Weatherhead PET Center for Preventing and Reversing Atherosclerosis. Dr. Gould is the 510(k) applicant for CFR Quant (510(k) number 113754) and HeartSee (510(k) numbers 143664, 171303), software for cardiac positron emission tomography processing, analysis, and absolute flow quantification. Dr. Johnson has an institutional licensing/consulting agreement with Boston Scientific for the smart minimum FFR algorithm; and has received institutional research support from St. Jude Medical (CONTRAST, NCT02184117) and Volcano/Philips Corporation (DEFINE-FLOW, NCT02328820) for studies using intracoronary pressure/flow sensors.
- Received July 3, 2018.
- Accepted July 30, 2018.
- 2018 The Authors
- Central Illustration
- “Normal” Angiogram and Coronary Physiology of Microvascular Angina
- Analytical Synthesis of Published Reports on Myocardial Perfusion in Microvascular Angina
- CFC: Simultaneous Assessment of Rest and Stress Flow
- Subendocardial Ischemia: The Underappreciated Elephant in the Room
- Precision Physiology Essential for Diagnosis and Management
- Microvascular Angina versus Subendocardial Ischemia: Mechanisms and Imaging
- Mechanism for Subendocardial Perfusion During Vasodilator Stress
- Precision Physiology: CFR versus CFC for Microvascular Angina and Major Adverse Cardiovascular Events
- Precision Perfusion for Angina Without Angiographic Stenosis
- Physiological Classification of No Stenosis Angina
- Prevalence and Clinical Outcomes
- An Unexpected but Objective Truth
- No Stenosis Angina With High Coronary Stress Flow
- Summary and Conclusions