Abstract
Obesity related coronary microvascular disease is a medical entity which is not yet fully elucidated. The pathophysiological basis of coronary microcirculatory dysfunction consists of a heterogeneous group of disorders with individual morphologic/functional/clinical presentation and prognosis. Coronary microcirculatory changes include mechanisms connected with vascular dysfunction, as well as extravascular and vasostructural changes in responses to neural, mechanical, and metabolic factors. Cardiometabolic changes that include obesity, dyslipidemia, diabetes mellitus type II, and hypertension are associated with atherosclerosis of epicardial coronary arteries and/or microvascular coronary dysfunction, with incompletely understood underlying mechanisms. In obesity, microvascular disease is mediated via adipokines/cytokines causing chronic, subclinical inflammation with (a) reduced NO-mediated dilatation, (b) changed endothelial- and smooth muscle-dependent vasoregulating mechanisms, (c) altered vasomotor control with increased sympathetic activity, and (d) obesity related hypertension with cardiomyocytes hypertrophy and impaired cardiac vascular adaptation to metabolic needs. From a clinical point of view it can present itself in acute or chronic form with different prognosis, as a practice problem for real-life diagnosis and treatment.
Highlights
Obesity is a direct or indirect risk factor for cardiovascular diseases and complications contributing to morbidity and mortality
Cardiometabolic changes that include obesity, dyslipidemia, diabetes mellitus type II, and hypertension are associated with atherosclerosis of epicardial coronary arteries and/or microvascular coronary dysfunction, with incompletely understood underlying mechanisms
Adipose tissue constitutes 18–24% of total body weight while in an obese person it constitutes 52–74% [6], which cannot stand without consequential hemodynamic, metabolic, and endocrinological responses in heart morphology and function which acts as an endocrine and immunoregulatory organ [7]
Summary
Obesity is a direct or indirect risk factor for cardiovascular diseases and complications contributing to morbidity and mortality. Coronary circulation commences from the aorta where oxygenated blood flows into the main right and main left coronary arteries and branches into smaller arteries, arterioles, capillaries, venules, and the veins. These vessels network begins in the epicardium and penetrates to myocardium where coronary microcirculation includes vessels with diameters below 300 μm and represents the “business end” of coronary circulation, where coronary arterial flow is exclusively diastolic and venous outflow is systolic [8, 9]. Dysfunction of coronary microcirculation or cardiac syndrome X is defined as reduced coronary flow reserve and/or endothelial dysfunction, presented with typical angina in absence of other myocardial/cardiovascular or systemic diseases, with electrocardiographic ischemic changes and normal/minimally changed coronarogram [7, 12, 13]. In clinical practice there are limitations for morphologic and functional visualization of coronary microcirculation in vivo with standard diagnostic methods [16, 17]
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