Anatomy and physiology of coronary blood flow

Abstract

Regional myocardial blood flow can now be measured noninvasively in units of milliliters blood per minute per gram myocardium. These noninvasive measurements are not confined to a specific imaging modality but are available with MRI, CT, and PET, although, thus far, most investigations of the coronary circulation in humans have employed PET flow measurements. Flow estimates with these different imaging modalities were found in animal experiments to correlate well with invasive flow estimates by the arterial blood sampling-microsphere technique widely considered as the “gold standard” of flow measurements.1-11 In these comparison studies, noninvasively-derived estimates corresponded linearly with invasively-measured myocardial blood flows over a wide flow range, i.e., from as low as 0.3 mL/minute/g to as high as 5-6 mL/minute/g. When tested in the human heart, noninvasive flow estimates correlated well with those obtained through invasively-obtained indices of flow and its changes by well-established alternate measurement approaches.12-16 Development and commercial availability of user-friendly software programs have facilitated the use of these new measurement capabilities so that they are now readily available in the clinical environment for the study of patients with cardiovascular disease. As several investigations have indicated, measurements of myocardial blood flow at rest contain only limited diagnostic information. For example, even in patients with advanced cardiovascular disease such as nonischemic dilated or ischemic cardiomyopathy, hypertrophic cardiomyopathy, or coronary artery disease, resting myocardial blood flows frequently are similar to those in normal individuals.17-19 It is the response of myocardial blood flow to specifically-targeted pharmacological or physiological interventions that can uncover the presence of functional or structural disease-related alterations of the coronary circulation. This then underscores the need for closely examining these targets and how they relate to anatomical and functional determinants of coronary blood flow and, by inference, to myocardial blood flow and their alterations in cardiovascular disease. Local and systemic mechanisms regulate the complex interactions between flow and anatomy in order to meet the heart’s energy needs. A comprehensive description of the coronary circulatory function and its control exceeds the scope of this review so that the interested reader is referred to detailed reviews on this topic.20,21 This review then seeks to describe in broad strokes the major functional and anatomical determinants of coronary blood flow as they pertain to noninvasive measured myocardial blood flows.