Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark.
Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark.
Eur Heart J. 2021 Jan 20;42(3):228-239. doi: 10.1093/eurheartj/ehaa944.
Many patients with angina, especially women, do not have obstructive coronary artery disease (CAD) yet have impaired prognosis. We investigated whether routine assessment of coronary microvascular dysfunction (CMD) is feasible and predicts adverse outcome in women with angina and no obstructive CAD.
After screening 7253, we included 1853 women with angina and no obstructive CAD on angiogram who were free of previous CAD, heart failure, or valvular heart disease in the prospective iPOWER (Improving Diagnosis and Treatment of Women with Angina Pectoris and Microvascular Disease) study. CMD was assessed by Doppler echocardiography in the left anterior descending artery as coronary flow velocity reserve (CFVR). Patients were followed for a composite outcome of cardiovascular death, myocardial infarction (MI), heart failure, stroke, and coronary revascularization. CFVR was obtained in 1681 patients (91%) and the median CFVR was 2.33 (quartiles 1-3: 2.00-2.74). During a median follow-up of 4.5 years, 96 events occurred. In univariate Cox regression, CFVR was associated with the composite outcome {hazard ratio (HR) 1.07 [95% confidence interval (CI) 1.03-1.11] per 0.1 unit decrease in CFVR; P < 0.001}, primarily driven by an increased risk of MI and heart failure. Results remained significant in multivariate analysis [HR 1.05 (95% CI 1.01-1.09) per 0.1 unit decrease in CFVR; P = 0.01]. In exploratory analyses, CFVR was also associated with the risk of repeated hospital admission for angina and all-cause mortality.
Assessment of CFVR by echocardiography is feasible and predictive of adverse outcome in women with angina and no obstructive CAD. Results support a more aggressive preventive management of these patients and underline the need for trials targeting CMD.
许多心绞痛患者，尤其是女性，并无阻塞性冠状动脉疾病（CAD），但预后不良。我们研究了常规评估冠状动脉微血管功能障碍（CMD）是否可行，并预测有无阻塞性 CAD 的心绞痛女性患者的不良预后。
在对 7253 例患者进行筛查后，我们纳入了前瞻性 iPOWER（改善女性心绞痛和微血管疾病的诊断和治疗）研究中的 1853 例无既往 CAD、心力衰竭或瓣膜性心脏病的心绞痛且造影无阻塞性 CAD 的女性患者。采用多普勒超声心动图评估左前降支冠状动脉血流储备（CFVR）以评估 CMD。对患者进行心血管死亡、心肌梗死（MI）、心力衰竭、卒中和冠状动脉血运重建的复合终点随访。1681 例患者（91%）获得了 CFVR，中位数 CFVR 为 2.33（四分位距 1-3：2.00-2.74）。中位随访 4.5 年后，发生了 96 例事件。在单变量 Cox 回归中，CFVR 与复合终点相关{风险比（HR）每降低 0.1 单位 CFVR 为 1.07（95%置信区间（CI）为 1.03-1.11）；P<0.001}，主要归因于 MI 和心力衰竭风险增加。多变量分析结果仍有意义[每降低 0.1 单位 CFVR 的 HR 为 1.05（95% CI 为 1.01-1.09）；P=0.01]。在探索性分析中，CFVR 也与因心绞痛再次住院和全因死亡率的风险相关。
超声心动图评估 CFVR 是可行的，并且可预测有无阻塞性 CAD 的心绞痛女性患者的不良预后。结果支持对这些患者进行更积极的预防治疗，并强调需要针对 CMD 进行临床试验。
