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Original research
Haemodynamic and metabolic adaptations in coronary microvascular disease
  1. Samer Noaman1,2,3,
  2. David M Kaye1,2,
  3. Shane Nanayakkara1,2,
  4. Anthony M Dart1,
  5. Andy S C Yong4,
  6. Martin Ng5,6,
  7. Donna Vizi1,
  8. Stephen J Duffy1,
  9. Nicholas Cox3,
  10. William Chan1,2
  1. 1Cardiology, Alfred Health, Melbourne, Victoria, Australia
  2. 2Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
  3. 3Western Health, Footscray, Victoria, Australia
  4. 4Cardiology, Concord Hospital, Sydney, New South Wales, Australia
  5. 5Medicine, The University of Sydney, Sydney, New South Wales, Australia
  6. 6Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
  1. Correspondence to Dr William Chan, Cardiology, Alfred Hospital, Melbourne, VIC 3004, Australia; william.chan{at}


Objective We aimed to evaluate the microcirculatory resistance (MR) and myocardial metabolic adaptations at rest and in response to increased cardiac workload in patients with suspected coronary microvascular dysfunction (CMD).

Methods Patients with objective ischaemia and/or myocardial injury and non-obstructive coronary artery disease underwent thermodilution-derived microcirculatory assessment and transcardiac blood sampling during graded exercise with adenosine-mediated hyperaemia. We measured MR at rest and following supine cycle ergometry. Patients (n=24) were stratified by the resting index of MR (IMR) into normal-IMR (IMR<22U, n=12) and high-IMR groups (IMR≥22U, n=12).

Results The mean age was 57 years; 67% were males and 38% had hypertension. The normal-IMR group had increased IMR response to exercise (16±5 vs 23±12U, p=0.03) compared with the high-IMR group, who had persistently elevated IMR at rest and following exercise (38±19 vs 33±15U, p=0.39) despite similar exercise duration and rate-pressure product between the groups, both p>0.05. The normal-IMR group had augmented oxygen extraction ratio following exercise (53±18 vs 64±11%, p=0.03) compared with the high-IMR group (65±14 vs 59±11%, p=0.26). The postexercise lactate uptake was greater in the high-IMR (0.04±0.05 vs 0.11±0.07 mmol/L, p=0.004) compared with normal-IMR group (0.08±0.06 vs 0.09±0.09 mmol/L, p=0.67). The high-IMR group demonstrated greater troponin release following exercise compared with the normal-IMR group (0.13±0.12 vs 0.001±0.05 ng/L, p=0.03).

Conclusions Patients with suspected CMD appear to have distinctive microcirculatory resistive and myocardial metabolic profiles at rest and in response to exercise. These differences in phenotypes may permit individualised therapies targeting microvascular responsiveness (normal-IMR group) and/or myocardial metabolic adaptations (normal-IMR and high-IMR groups).

  • Coronary Angiography
  • Angina Pectoris
  • Acute Coronary Syndrome
  • Microvascular Angina

Data availability statement

Data are available on reasonable request.

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Data availability statement

Data are available on reasonable request.

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  • Contributors All authors contributed to the manuscript. WC is responsible for the overall content as guarantor.

  • Funding This study was supported by Harold and Cora Brennen Benevolent Trust and Abbott Vascular. Abbott Vascular provided the coronary guidewires used in the study but had no part in the design, data analysis, manuscript preparation or decision to publish this work. SN is supported by the Australian National Health Foundation (Health Professional Scholarship Award ID 102336) and the National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Cardiovascular Outcome Improvement (CRECOI Scholarship).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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