Coronary Microvascular Dysfunction in Takotsubo Syndrome Assessed by Angiography-Derived Index of Microcirculatory Resistance: A Pressure-Wire-Free Tool.

Jordi Sans-Roselló,Estefanía Fernández-Peregrina,Albert Duran-Cambra,Hector M Garcia-Garcia,Alessandro Sionis,Jose Carreras-Mora,Jesús Álvarez-García

doi:10.3390/jcm10194331

Abstract

Background: Coronary microvascular dysfunction (CMD) has been proposed as a key mechanism in Takotsubo syndrome (TTS). The non-hyperaemic angiography-derived index of microcirculatory resistance (NH-IMRangio) has been validated as a pressure-wire-free tool for the assessment of coronary microvasculature. We aimed to study the presence of CMD in TTS patients and its association with levels of cardiac biomarkers and systolic dysfunction patterns. Methods: We recruited 181 consecutive patients admitted for TTS who underwent cardiac angiography at a tertiary center from January 2014 to January 2021. CMD was defined as an NH-IMRangio ≥ 25. Plasma levels of NT-proBNP, high-sensitive cardiac troponin T (hs-cTnT) and the left ventricular ejection fraction (LVEF) by echocardiography were measured at admission. Results: Mean age was 75.3 years, 83% were women and median LVEF was 45%. All patients presented CMD (NH-IMRangio ≥ 25) in at least one epicardial coronary artery. The left anterior descending artery (LAD) showed higher median NH-IMRangio values than left circumflex (LCx) and right coronary arteries (RCA) (44.6 vs. 31.3 vs. 36.1, respectively; p < 0.001). NH-IMRangio values differed among ventricular contractility patterns in the LAD and RCA (p = 0.0152 and 0.0189, respectively) with the highest values in the mid-ventricular + apical and mid-ventricular + basal patterns. NT-proBNP levels, but not high-sensitive cardiac troponin T (hs-cTnT), were correlated with both the degree and the extent of CMD in patients with TTS. Lower LVEF was also associated with higher NH-IMRangio values. Conclusions: CMD is highly prevalent in patients admitted for TTS and is associated with both a higher degree of systolic dysfunction and higher BNP levels, but not troponin.

Highlights

Takotsubo syndrome (TTS) [1] is an acute and transient ventricular dysfunction with symptoms and electrocardiographic abnormalities that mimics acute myocardial infarction in the absence of obstructive epicardial coronary artery disease
Several mechanisms have involved in TTS, such as 1. a sudden surge in catecholamines and activation of the sympathetic nervous system [6,7]; 2. an acute and transient coronary microvascular dysfunction (CMD) [8,9,10,11,12,13,14]
An angiography-derived index of microcirculatory resistance (IMRangio), which is a novel angiography based index derived from the application of computational flow dynamics to three-dimensional modeling of the coronary artery and contrast flow by thrombolysis in the myocardial infarction (TIMI) frame count, has been recently introduced [25]

Summary

Introduction

Takotsubo syndrome (TTS) [1] is an acute and transient ventricular dysfunction with symptoms and electrocardiographic abnormalities that mimics acute myocardial infarction in the absence of obstructive epicardial coronary artery disease. CMD can be evaluated with different diagnostic methods: the index of microcirculatory resistance (IMR) is a quantitative and reproducible, wire-based method for invasively assessing the coronary microvascular function independent of the epicardial arteries [15]. Coronary microvascular dysfunction (CMD) has been proposed as a key mechanism in Takotsubo syndrome (TTS). We aimed to study the presence of CMD in TTS patients and its association with levels of cardiac biomarkers and systolic dysfunction patterns. All patients presented CMD (NH-IMRangio ≥ 25) in at least one epicardial coronary artery. The left anterior descending artery (LAD) showed higher median NH-IMRangio values than left circumflex (LCx) and right coronary arteries (RCA)

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