VA Boston Healthcare System, Boston, Massachusetts, USA; Boston University School of Medicine, Boston, Massachusetts, USA.
Cardiology Department, University of Pisa, Pisa, Italy.
J Am Coll Cardiol. 2023 Feb 7;81(5):505-514. doi: 10.1016/j.jacc.2022.08.814.
Management of stable coronary artery disease (CAD) has been based on the assumption that flow-limiting atherosclerotic obstructions are the proximate cause of angina and myocardial ischemia in most patients and represent an important target for revascularization. However, the role of revascularization in reducing long-term cardiac events in these patients has been limited mainly to those with left main disease, 3-vessel disease with diabetes, or decreased ejection fraction. Mounting evidence indicates that nonepicardial coronary causes of angina and ischemia, including coronary microvascular dysfunction, vasospastic disorders, and derangements of myocardial metabolism, are more prevalent than flow-limiting stenoses, raising concerns that many important causes other than epicardial CAD are neither considered nor probed diagnostically. There is a need for a more inclusive management paradigm that uncouples the singular association between epicardial CAD and revascularization and better aligns diagnostic approaches that tailor treatment to the underlying mechanisms and precipitants of angina and ischemia in contemporary clinical practice.
稳定型冠状动脉疾病（CAD）的管理一直基于这样一种假设，即限制血流的动脉粥样硬化阻塞是大多数患者心绞痛和心肌缺血的直接原因，也是血运重建的重要目标。然而，血运重建在减少这些患者的长期心脏事件方面的作用主要局限于左主干疾病、有糖尿病的 3 支血管疾病或射血分数降低的患者。越来越多的证据表明，心绞痛和缺血的非心外膜冠状动脉原因，包括冠状动脉微血管功能障碍、血管痉挛性疾病和心肌代谢紊乱，比限制血流的狭窄更为常见，这引发了人们的担忧，即许多重要的病因除了心外膜 CAD 以外，既没有得到考虑，也没有在诊断上进行探查。需要一种更具包容性的管理模式，将心外膜 CAD 和血运重建之间的单一关联分离出来，并更好地调整诊断方法，根据潜在机制和引发心绞痛和缺血的诱因来调整治疗方法，以适应当代临床实践。
