Rinaldi Riccardo, Salzillo Carmine, Caffè Andrea, Montone Rocco A
Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy.
Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy.
Rev Cardiovasc Med. 2022 Oct 31;23(11):371. doi: 10.31083/j.rcm2311371. eCollection 2022 Nov.
Despite ischemic heart disease (IHD) has been commonly identified as the consequence of obstructive coronary artery disease (OCAD), a significant percentage of patients undergoing coronary angiography because of signs and/or symptoms of myocardial ischemia do not have any significant coronary artery stenosis. Several mechanisms other than coronary atherosclerosis, including coronary microvascular dysfunction (CMD), coronary endothelial dysfunction and epicardial coronary vasospasm, can determine myocardial ischemia or even myocardial infarction in the absence of flow-limiting epicardial coronary stenosis, highlighting the need of performing adjunctive diagnostic tests at the time of coronary angiography to achieve a correct diagnosis. This review provides updated evidence of the pathophysiologic mechanisms of myocardial ischemia with non-obstructive coronary arteries, focusing on the diagnostic and therapeutic implications of performing a comprehensive invasive functional evaluation consisting of the assessment of both vasodilation and vasoconstriction disorders. Moreover, performing a comprehensive invasive functional assessment may have important prognostic and therapeutic implications both in patients presenting with myocardial ischemia with non-obstructive coronary arteries (INOCA) or myocardial infarction with non-obstructive coronary arteries (MINOCA), as the implementation of a tailored patient management demonstrated to improve patient's symptoms and prognosis. However, given the limited knowledge of myocardial ischaemia with non-obstructive coronary arteries, there are no specific therapeutic interventions for these patients, and further research is warranted aiming to elucidate the underlying mechanisms and risk factors and to develop personalized forms of treatment.
尽管缺血性心脏病（IHD）通常被认为是阻塞性冠状动脉疾病（OCAD）的后果，但因心肌缺血的体征和/或症状而接受冠状动脉造影的患者中，有相当一部分没有明显的冠状动脉狭窄。除冠状动脉粥样硬化外，其他几种机制，包括冠状动脉微血管功能障碍（CMD）、冠状动脉内皮功能障碍和心外膜冠状动脉痉挛，可在无血流限制性心外膜冠状动脉狭窄的情况下导致心肌缺血甚至心肌梗死，这凸显了在冠状动脉造影时进行辅助诊断测试以实现正确诊断的必要性。本综述提供了关于非阻塞性冠状动脉心肌缺血病理生理机制的最新证据，重点关注进行包括血管舒张和血管收缩障碍评估的全面侵入性功能评估的诊断和治疗意义。此外，进行全面侵入性功能评估可能对非阻塞性冠状动脉心肌缺血（INOCA）或非阻塞性冠状动脉心肌梗死（MINOCA）患者具有重要的预后和治疗意义，因为实施个性化的患者管理已证明可改善患者症状和预后。然而，鉴于对非阻塞性冠状动脉心肌缺血的了解有限，这些患者没有特定的治疗干预措施，因此有必要进行进一步研究，以阐明潜在机制和危险因素，并开发个性化的治疗形式。
