Endothelial Dysfunction and Coronary Vasoreactivity - A Review of the History, Physiology, Diagnostic Techniques, and Clinical Relevance

Abstract

: The fervency for advancement and evolution in percutaneous coronary intervention has revolutionised the treatment of coronary artery disease. Historically, the focus of the interventional cardiologist was directed at the restoration of luminal patency of the major epicardial coronary arteries, yet whilst this approach is evolving with a much greater utilisation of physiological assessment, it often neglects consideration of the role of the coronary microcirculation which has been shown to clearly influence prognosis. In this review, we consider exploring the narrative of the coronary circulation as more than just a simple conduit for blood but an organ with functional significance. We discuss the organisation and physiology of the coronary circulation as well as the current methods and techniques used to examine it. We then review the studies exploring coronary artery endothelial function, appreciating that coronary artery disease occurs on a spectrum of disorder and that percutaneous coronary intervention has a latent effect on the coronary circulation with long-term consequences. We conclude that greater recognition of the coronary artery endothelium and mechanisms of the coronary circulation should guide revascularisation strategies further.

Cardiac computed tomography-derived coronary artery volume to myocardial mass

“…It is recognised that endothelial dependent and independent mechanisms of vasodilation in the microvasculature directly impact the vasodilatory capacity of epicardial vessels and therefore the coronary luminal volume. 36,37 In a cohort of patients with primary MVA, V/M was significantly lower compared to matched controls (25.6 AE 5.9 vs. 30.0 AE 6.5, p < 0.001). 16 This was driven predominantly by lower total coronary lumen volume in MVA patients (2302 AE 109 vs. 2978 AE 134 mm 3 , p < 0.001), highlighting that the vasodilatory capacity of the epicardial vessels (i.e coronary luminal volume) is potentially related to microvascular function.…”

“…8 INOCA is not without risk and is associated with adverse prognosis, significant symptomatic limitation and impairment to quality of life. 58 Given the relationship of endothelial function with epicardial coronary vasoreactivity 37 and therefore luminal dimensions, CCTA in combination with V/M data could provide further personalised risk assessment for patients with no-evident or non-obstructive CAD. Improved risk assessment could augment management strategies such as intensifying existing treatments (lowhigh intensity statins), monitoring the physiological response to pharmacotherapies (e.g.…”

The Role of Endothelial Progenitor Cells in Atherosclerosis and Impact of Anti-Lipemic Treatments on Endothelial Repair

“…Damaged vessels lose their vasoactive ability due to impaired synthesis of vasoactive substances, but also because of increased rigidity due to structural changes of the vessel wall. Endothelial dysfunction may be the first step leading to more serious conditions like accelerated atherosclerosis and associated vascular complications [ 16 , 38 ].…”

Drug-Coated Balloon vs. Drug-Eluting Stents for De Novo Unprotected Left Main Stem Disease: The SPARTAN-LMS Study

“…Drug-coated balloons (DCBs) are a guideline-recommended treatment for in-stent restenosis (ISR), with a growing amount of data demonstrating their long-term efficacy in small-vessel de novo disease [ 18 , 19 , 20 ]. It can potentially reduce the strategic complexity of treating important LMS bifurcation, which can otherwise necessitate intricate stenting approaches [ 21 ], whilst mitigating the concerning risk of stent thrombosis in this scenario and promoting reduced sheer stress and natural vasomotion [ 22 , 23 ]. To date, there is only scarce evidence of DCB utilisation in LMS disease, limited mainly to ISR LMS lesions [ 12 , 24 ].…”