Incidence, Clinical Factors, and Endotype Characterization of Coronary Microvascular Dysfunction in Patients With Non-Obstructive Coronary Artery Disease Undergoing ¹³N-Ammonia Positron Emission Tomography

Coronary microvascular dysfunction (CMD) is characterized by impaired myocardial flow reserve (MFR) in patients with non-obstructive coronary artery disease (CAD). The real-world incidence of CMD, risk factors for decreased MFR, and characteristics of the two CMD endotypes (classical and endogenous) in this population remain unclear. After screening 1,313 patients with suspected or known CAD who underwent 13N-ammonia positron emission tomography (PET), 345 with non-obstructive CAD were retrospectively enrolled in the study. Stress/resting myocardial blood flow (MBF) was quantified using 13N-ammonia PET. PET-assessed CMD (impaired MFR <2.0) was diagnosed in 60 (17%) patients. Independent predictors of decreased MFR included older age, female sex, anemia, and hypertension; however, these factors accounted for only 32% of the observed variability in MFR. Symptomatic status was not an independent predictor of decreased MFR. Patients with classical CMD (resting MBF <1.3 mL/min/g) had higher summed stress scores and stress/resting coronary vascular resistance, whereas patients with endogenous CMD (resting MBF ≥1.3 mL/min/g) showed female dominance, higher stress MBF, and a higher resting rate-pressure product. Among patients with non-obstructive CAD, approximately 1 in 5 had PET-assessed CMD. Age, female sex, anemia, and hypertension were independent clinical factors associated with impaired MFR, which explained a limited portion of its variability. Further examination of unidentified or unmeasured factors is warranted.