Key result
Coronary microvascular dysfunction linked to ~91% higher risk of major cardiovascular events.
Why the study?
Coronary microvascular dysfunction often coexists with epicardial coronary artery disease, but data regarding its prevalence and prognosis in patients undergoing invasive coronary angiography are scarce.
Does coronary microvascular dysfunction increase the risk of adverse cardiovascular outcomes in patients undergoing invasive coronary angiography?
Cohort (n=1,003)
Yes
Does coronary microvascular dysfunction increase the risk of adverse cardiovascular outcomes in patients undergoing invasive coronary angiography?
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Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Current guidelines mainly recommend physiological assessment of microvascular dysfunction for patients without coronary artery stenosis. In this study, the prevalence of microvascular dysfunction was higher in patients with stenosis, and the associated risk was greater when microvascular dysfunction was present, so physiological assessment should also be recommended for patients with stenosis.”
“Coronary microvascular dysfunction (CMD) puts patients at greater risk for death, heart attack, repeat revascularization and heart failure (HF) hospitalization, and patients with or without epicardial coronary artery disease (CAD) should be evaluated for CMD, according to data from a new registry analysis.”
“The findings show that CMD is an independent predictor of adverse cardiovascular outcomes, even after adjusting for epicardial coronary artery disease, indicating that evaluation of only large coronary vessels may miss an important aspect of ischemic risk.”
In patients undergoing invasive coronary angiography, the presence of coronary microvascular dysfunction is associated with a nearly twofold increased risk of adverse cardiovascular events.
BACKGROUND: Coronary microvascular dysfunction often coexists with epicardial coronary artery disease. Data regarding its prevalence and prognosis in patients undergoing invasive coronary angiography are scarce. This study aimed to evaluate the prevalence and prognosis of coronary microvascular dysfunction in patients undergoing clinically indicated invasive coronary angiography in routine practice. METHODS: In this prospective, multicentre cohort study done in seven tertiary medical hospitals in South Korea, consecutive patients aged 18 years and older who were referred for clinically indicated invasive coronary angiography were systematically screened and evaluated by coronary physiological assessment. Obstructive epicardial coronary artery disease was defined as an intermediate stenosis (40-90% diameter stenosis), with fractional flow reserve of 0·80 or less or severe stenosis (>90% of diameter stenosis) treated with revascularisation without fractional flow reserve measurement. Coronary microvascular dysfunction was identified as coronary flow reserve below 2·0 and index of microcirculatory resistance of ≥25. The primary endpoint was a composite of all-cause death, myocardial infarction, clinically driven repeat revascularisation, or hospitalisation for heart failure. The Multicenter FLOW-CMD Registry study is registered with ClinicalTrials.gov (NCT05369182). FINDINGS: Between April 22, 2022, and Nov 19, 2024, 5764 patients were screened and 1003 patients were enrolled (756 men and 247 women). Among these patients, coronary microvascular dysfunction was observed in 123 (21·5%) of 573 patients with obstructive epicardial coronary artery disease and in 40 (9·3%) of 430 patients without obstructive epicardial coronary artery disease. At a median follow-up of 1·9 years, the primary endpoint occurred in 26 patients (2-year Kaplan-Meier estimate 18·8%) with coronary microvascular dysfunction and 70 patients (2-year Kaplan-Meier estimate 10·5%) with preserved microvascular function (hazard ratio 1·91 [95% CI 1·22-2·99]; p=0·0047). INTERPRETATION: In patients with suspected ischaemic heart disease undergoing invasive coronary angiography, coronary microvascular dysfunction coexisted with epicardial coronary artery disease and was associated with a higher risk of the composite of all-cause death, myocardial infarction, clinically driven repeat revascularisation, or hospitalisation for heart failure.
Lee et al. (2026) conducted a cohort in suspected ischaemic heart disease undergoing invasive coronary angiography (n=1,003). Coronary microvascular dysfunction vs. Preserved microvascular function was evaluated on composite of all-cause death, myocardial infarction, clinically driven repeat revascularisation, or hospitalisation for heart failure (HR 1.91, 95% CI 1.22-2.99, p=0.0047). Coronary microvascular dysfunction was associated with a higher risk of death, MI, repeat revascularisation, or heart failure hospitalisation.
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