Coronary microvascular dysfunction and obstructive coronary artery disease in sepsis-associated myocardial injury: authors’ reply

Q: What is the clinical evidence from this study?

Study design: Letter. Population: Sepsis-associated myocardial injury (n=55). Intervention: Protocol coronary angiography and microvascular physiological assessment (IMR and MRR) vs. Matched cohort of patients with chronic coronary syndromes; patients without obstructive CAD vs. with obstructive CAD. Primary outcome: Obstructive coronary artery disease (CAD) identified on protocol coronary angiography (AUC 0.69 for number of conventional cardiovascular risk factors, 95% CI 0.55-0.83).

Q: What does this research mean for the field?

In patients with sepsis-associated myocardial injury, conventional cardiovascular risk factors provide the greatest discriminatory ability for identifying obstructive coronary artery disease, whereas high-sensitivity cardiac troponin T levels offer limited incremental value. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Samantha Lörstad; Per Åstrand; Patrik Gille-Johnson; Yunzhang Wang; Christina Ekenbäck; Fadi Jokhaji; Felix Böhm; Patrik Hjalmarsson; Shajan Shekarestan; Tomas Jernberg; Sara Tehrani; Kambiz Shahgaldi; Jonas Persson

doi:10.1186/s13054-026-06422-x

November 2, 2026Critical CareOpen Access

Coronary microvascular dysfunction and obstructive coronary artery disease in sepsis-associated myocardial injury: authors’ reply

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Why the study?

Does pre-angiography clinical and biomarker assessment identify obstructive coronary artery disease in stabilised patients with sepsis and elevated troponin?

Key Points

To address diagnostic criteria for coronary microvascular dysfunction and evaluate predictors of obstructive coronary artery disease in sepsis-associated myocardial injury.
Assessed coronary angiography and microvascular physiology (index of microcirculatory resistance and microvascular resistance reserve) in stabilized, vasopressor-free patients with sepsis and elevated high-sensitivity cardiac troponin T (hs-cTnT ≥ 15 ng/L).
Conducted post hoc receiver operating characteristic analyses to assess the ability of pre-angiography clinical variables to discriminate obstructive coronary artery disease.
Obstructive coronary artery disease was present in 12 of 55 patients (22%), with 6 patients undergoing percutaneous coronary intervention during the index hospitalization.
The number of conventional cardiovascular risk factors showed the highest discrimination for obstructive coronary artery disease (AUC 0.69, 95% CI 0.55–0.83), whereas highest recorded hs-cTnT had an AUC of 0.62 (95% CI 0.42–0.82).
A multivariable model combining hypertension, diabetes mellitus, regional wall-motion abnormalities, and hs-cTnT had an apparent AUC of 0.73 (95% CI 0.54–0.91), which decreased to 0.64 (95% CI 0.45–0.82) after bootstrap optimism correction.

Structured PICO

Does pre-angiography clinical and biomarker assessment identify obstructive coronary artery disease in stabilised patients with sepsis and elevated troponin?

P

Population

55 stabilised patients with sepsis and hs-cTnT ≥ 15 ng/L undergoing protocol coronary angiography (49 with microvascular physiological assessment).

E

Exposure

Invasive protocol coronary angiography and coronary microvascular physiology assessment (index of microcirculatory resistance [IMR] and microvascular resistance reserve [MRR] measured in the left anterior descending artery), plus percutaneous coronary intervention (PCI) and guideline-directed medical therapy where indicated.

C

Comparator

Matched cohort of patients with chronic coronary syndromes (for microvascular assessment); patients stratified by angiographic findings into obstructive CAD with index PCI (n=6), obstructive CAD without index PCI (n=6), and no obstructive CAD (n=43).

O

Outcome

Presence of obstructive coronary artery disease (CAD) and coronary microvascular dysfunction (CMD, defined as IMR > 25 and MRR ≤ 3).surrogate

Main Result

Effect estimate: AUC 0.69 for number of conventional cardiovascular risk factors (95% CI 0.55-0.83)

Limitations

Small sample size
Lack of external validation
Post hoc exploratory ROC analysis
Cross-sectional associations may be confounded by illness severity and do not establish causality
Single-vessel measurements in the LAD may not capture regional heterogeneity, particularly in the right coronary territory
Thresholds used to define CMD (IMR > 25 and MRR ≤ 3) were derived from studies of chronic coronary syndromes rather than sepsis
Lack of external validation for the post hoc exploratory ROC analysis

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

In stabilised patients with sepsis-associated myocardial injury, conventional cardiovascular risk factors and regional wall-motion abnormalities may help guide selective coronary angiography for obstructive CAD, whereas peak hs-cTnT levels offer limited discriminatory value.

Abstract

This reply refers to the comment available online at h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 3 0 5 4 -0 2 6 -0 6 2 3 1 -2 .This reply refers to the comment available online at h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6

Discussion

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Cite This Study

Lörstad et al. (2026) conducted a letter in Sepsis-associated myocardial injury (n=55). Protocol coronary angiography and microvascular physiological assessment (IMR and MRR) vs. Matched cohort of patients with chronic coronary syndromes; patients without obstructive CAD vs. with obstructive CAD was evaluated on Obstructive coronary artery disease (CAD) identified on protocol coronary angiography (AUC 0.69 for number of conventional cardiovascular risk factors, 95% CI 0.55-0.83).

synapsesocial.com/papers/6aebc8ba3e63ca1b6c315df7 https://doi.org/10.1186/s13054-026-06422-x

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Coronary microvascular dysfunction and obstructive coronary artery disease in sepsis-associated myocardial injury: authors’ reply

Key Points

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Coronary microvascular dysfunction and obstructive coronary artery disease in sepsis-associated myocardial injury: authors’ reply

Key Points

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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