Progress in the development of mechanisms and assessment tools for coronary microvascular dysfunction after acute myocardial infarction_West China Medical Journal

Authors：

ZHANG Hui ^1,2 , SHANGGUAN Haijuan ¹ ,  WANG Min ¹

1. Department of Cardiology, Wuhan Asia Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, Hubei 430022, P. R. China;
2. Medical College, Wuhan University of Science and Technology, Wuhan, Hubei 430065, P. R. China;

Corresponding author：

WANG Min, Email: zeta331@aliyun.com

Keywords：

Acute myocardial infarction; coronary microvascular dysfunction; magnetic resonance imaging

DOI：

10.7507/1002-0179.202503177

Video：

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Abstract Full text Figures/Tables Video References Cited by

Coronary microvascular dysfunction (CMD), as an urgent clinical challenge after percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI), has become a research hotspot in the cardiovascular field for its pathophysiological mechanisms and early accurate assessment strategies. The paper systematically summarizes the molecular mechanisms of CMD after reperfusion therapy in STEMI patients, and at the level of diagnostic technology, it deeply analyzes the clinical application value of invasive assessment tools such as coronary flow reserve fraction and index of microcirculatory resistance, and focuses on the unique advantages of quantitative cardiac magnetic resonance analysis for visual assessment of microcirculatory function, aiming to construct a multidimensional assessment system for CMD after STEMI, which will provide a theoretical basis for optimizing the risk stratification of cardiovascular events and formulating individualized treatment strategies.

Citation： ZHANG Hui, SHANGGUAN Haijuan, WANG Min. Progress in the development of mechanisms and assessment tools for coronary microvascular dysfunction after acute myocardial infarction. West China Medical Journal, 2025, 40(8): 1327-1332. doi: 10.7507/1002-0179.202503177 Copy

1.	Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022, 145(3): e4-e17.
2.	Konijnenberg LSF, Damman P, Duncker DJ, et al. Pathophysiology and diagnosis of coronary microvascular dysfunction in ST-elevation myocardial infarction. Cardiovasc Res, 2020, 116(4): 787-805.
3.	Kelshiker MA, Seligman H, Howard JP, et al. Coronary flow reserve and cardiovascular outcomes: a systematic review and meta-analysis. Eur Heart J, 2022, 43(16): 1582-1593.
4.	Niccoli G, Montone RA, Ibanez B, et al. Optimized treatment of ST-elevation myocardial infarction. Circ Res, 2019, 125(2): 245-258.
5.	Reffelmann T, Kloner RA. The no-reflow phenomenon: a basic mechanism of myocardial ischemia and reperfusion. Basic Res Cardiol, 2006, 101(5): 359-372.
6.	Huertas J, Lee HT. Multi-faceted roles of cathepsins in ischemia reperfusion injury (Review). Mol Med Rep, 2022, 26(6): 368.
7.	Liu Y, Zhang J, Zhang D, et al. Research progress on the role of pyroptosis in myocardial ischemia-reperfusion injury. Cells, 2022, 11(20): 3271.
8.	Heusch G. Myocardial ischaemia-reperfusion injury and cardioprotection in perspective. Nat Rev Cardiol, 2020, 17(12): 773-789.
9.	Kleinbongard P, Heusch G. A fresh look at coronary microembolization. Nat Rev Cardiol, 2022, 19(4): 265-280.
10.	Li Y, Yu J, Wang Y. Mechanism of coronary microcirculation obstruction after acute myocardial infarction and cardioprotective strategies. Rev Cardiovasc Med, 2024, 25(10): 367.
11.	Galli M, Niccoli G, De Maria G, et al. Coronary microvascular obstruction and dysfunction in patients with acute myocardial infarction. Nat Rev Cardiol, 2024, 21(5): 283-298.
12.	中华医学会心血管病学分会, 中华心血管病杂志编辑委员会. ST 段抬高型心肌梗死患者急诊 PCI 微循环保护策略中国专家共识. 中华心血管病杂志, 2022, 50(3): 221-230.
13.	Niccoli G, Scalone G, Lerman A, et al. Coronary microvascular obstruction in acute myocardial infarction. Eur Heart J, 2016, 37(13): 1024-1033.
14.	Gibson CM, Cannon CP, Daley WL, et al. TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation, 1996, 93(5): 879-888.
15.	Poyraz E, Savaş G, Erdem A, et al. The mean corrected TIMI frame count could predict major adverse cardiovascular events in patients with coronary slow-flow phenomenon. Turk Kardiyol Dern Ars, 2022, 50(4): 250-255.
16.	Ong P, Camici PG, Beltrame JF, et al. International standardization of diagnostic criteria for microvascular angina. Int J Cardiol, 2018, 250: 16-20.
17.	徐艺硕, 胡思宁, 贾海波, 等. 冠状动脉微循环侵入性诊疗用于急性 ST 段抬高型心肌梗死患者的研究进展. 中国介入心脏病学杂志, 2022, 30(5): 382-387.
18.	Maznyczka AM, Oldroyd KG, McCartney P, et al. The potential use of the index of microcirculatory resistance to guide stratification of patients for adjunctive therapy in acute myocardial infarction. JACC Cardiovasc Interv, 2019, 12(10): 951-966.
19.	Taqueti VR, Di Carli MF. Coronary microvascular disease pathogenic mechanisms and therapeutic options: JACC state-of-the-art review. J Am Coll Cardiol, 2018, 72(21): 2625-2641.
20.	Maznyczka AM, Oldroyd KG, Greenwood JP, et al. Comparative significance of invasive measures of microvascular injury in acute myocardial infarction. Circ Cardiovasc Interv, 2020, 13(5): e008505.
21.	严颖, 王碧雲, 卫华. 冠状动脉微血管疾病影像学应用的研究进展. 中西医结合心脑血管病杂志, 2023, 21(7): 1246-1249.
22.	段天兵, 向定成. 急性心肌梗死后冠状动脉微循环障碍发生机制和诊治方法的研究进展. 中国循环杂志, 2019, 34(7): 722-725.
23.	王岚, 马玉良, 王伟民, 等. 心肌声学造影评估急性心肌梗死患者血运重建后冠状动脉微循环障碍的研究. 中国循环杂志, 2021, 36(10): 985-990.
24.	Lam JH, Quah JX, Davies T, et al. Relationship between coronary microvascular dysfunction and left ventricular diastolic function in patients with chest pain and unobstructed coronary arteries. Echocardiography, 2020, 37(8): 1199-1204.
25.	张社芳, 王华, 王振华, 等. 超声造影对心肌微血管损伤的实验研究. 中国医学工程, 2022, 30(1): 17-20.
26.	Ong P, Safdar B, Seitz A, et al. Diagnosis of coronary microvascular dysfunction in the clinic. Cardiovasc Res, 2020, 116(4): 841-855.
27.	Everaars H, de Waard GA, Driessen RS, et al. Doppler flow velocity and thermodilution to assess coronary flow reserve: a head-to-head comparison with [¹⁵O]H₂O PET. JACC Cardiovasc Interv, 2018, 11(20): 2044-2054.
28.	Al-Mallah MH, Nayfeh M, Alrifai M. The role of cardiac PET in diagnosis and prognosis of patients with ischemia with no obstructive coronary arteries (INOCA). Am Heart J Plus, 2024, 43: 100399.
29.	Benenati S, Campo G, Seitun S, et al. Ischemia with non-obstructive coronary artery (INOCA): non-invasive versus invasive techniques for diagnosis and the role of #FullPhysiology. Eur J Intern Med, 2024, 127: 15-24.
30.	Schulz-Menger J, Bluemke DA, Bremerich J, et al. Standardized image interpretation and post-processing in cardiovascular magnetic resonance - 2020 update: Society for Cardiovascular Magnetic Resonance (SCMR): Board of Trustees Task Force on Standardized Post-Processing. J Cardiovasc Magn Reson, 2020, 22(1): 19.
31.	Patel AR, Salerno M, Kwong RY, et al. Stress cardiac magnetic resonance myocardial perfusion imaging: JACC review topic of the week. J Am Coll Cardiol, 2021, 78(16): 1655-1668.
32.	Kotecha T, Martinez-Naharro A, Boldrini M, et al. Automated pixel-wise quantitative myocardial perfusion mapping by CMR to detect obstructive coronary artery disease and coronary microvascular dysfunction: validation against invasive coronary physiology. JACC Cardiovasc Imaging, 2019, 12(10): 1958-1969.
33.	Bulluck H, Dharmakumar R, Arai AE, et al. Cardiovascular magnetic resonance in acute ST-segment-elevation myocardial infarction: recent advances, controversies, and future directions. Circulation, 2018, 137(18): 1949-1964.
34.	Symons R, Pontone G, Schwitter J, et al. Long-term incremental prognostic value of cardiovascular magnetic resonance after ST-segment elevation myocardial infarction: a study of the collaborative registry on CMR in STEMI. JACC Cardiovasc Imaging, 2018, 11(6): 813-825.
35.	Vora KP, Kumar A, Krishnam MS, et al. Microvascular obstruction and intramyocardial hemorrhage in reperfused myocardial infarctions: pathophysiology and clinical insights from imaging. JACC Cardiovasc Imaging, 2024, 17(7): 795-810.
36.	Ibanez B, Aletras AH, Arai AE, et al. Cardiac MRI endpoints in myocardial infarction experimental and clinical trials: JACC Scientific Expert Panel. J Am Coll Cardiol, 2019, 74(2): 238-256.
37.	蔡宜婷, 邢浩然, 郝明辉, 等. STEMI 再灌注微血管损伤的心脏磁共振成像新进展. 中华心血管病杂志, 2022(12): 1237-1242.
38.	Reinstadler SJ, Stiermaier T, Reindl M, et al. Intramyocardial haemorrhage and prognosis after ST-elevation myocardial infarction. Eur Heart J Cardiovasc Imaging, 2019, 20(2): 138-146.
39.	Vyas R, Changal KH, Bhuta S, et al. Impact of intramyocardial hemorrhage on clinical outcomes in ST-elevation myocardial infarction: a systematic review and meta-analysis. J Soc Cardiovasc Angiogr Interv, 2022, 1(6): 100444.
40.	Moon BF, Iyer SK, Hwuang E, et al. Iron imaging in myocardial infarction reperfusion injury. Nat Commun, 2020, 11(1): 3273.

1. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022, 145(3): e4-e17.
2. Konijnenberg LSF, Damman P, Duncker DJ, et al. Pathophysiology and diagnosis of coronary microvascular dysfunction in ST-elevation myocardial infarction. Cardiovasc Res, 2020, 116(4): 787-805.
3. Kelshiker MA, Seligman H, Howard JP, et al. Coronary flow reserve and cardiovascular outcomes: a systematic review and meta-analysis. Eur Heart J, 2022, 43(16): 1582-1593.
4. Niccoli G, Montone RA, Ibanez B, et al. Optimized treatment of ST-elevation myocardial infarction. Circ Res, 2019, 125(2): 245-258.
5. Reffelmann T, Kloner RA. The no-reflow phenomenon: a basic mechanism of myocardial ischemia and reperfusion. Basic Res Cardiol, 2006, 101(5): 359-372.
6. Huertas J, Lee HT. Multi-faceted roles of cathepsins in ischemia reperfusion injury (Review). Mol Med Rep, 2022, 26(6): 368.
7. Liu Y, Zhang J, Zhang D, et al. Research progress on the role of pyroptosis in myocardial ischemia-reperfusion injury. Cells, 2022, 11(20): 3271.
8. Heusch G. Myocardial ischaemia-reperfusion injury and cardioprotection in perspective. Nat Rev Cardiol, 2020, 17(12): 773-789.
9. Kleinbongard P, Heusch G. A fresh look at coronary microembolization. Nat Rev Cardiol, 2022, 19(4): 265-280.
10. Li Y, Yu J, Wang Y. Mechanism of coronary microcirculation obstruction after acute myocardial infarction and cardioprotective strategies. Rev Cardiovasc Med, 2024, 25(10): 367.
11. Galli M, Niccoli G, De Maria G, et al. Coronary microvascular obstruction and dysfunction in patients with acute myocardial infarction. Nat Rev Cardiol, 2024, 21(5): 283-298.
12. 中华医学会心血管病学分会, 中华心血管病杂志编辑委员会. ST 段抬高型心肌梗死患者急诊 PCI 微循环保护策略中国专家共识. 中华心血管病杂志, 2022, 50(3): 221-230.
13. Niccoli G, Scalone G, Lerman A, et al. Coronary microvascular obstruction in acute myocardial infarction. Eur Heart J, 2016, 37(13): 1024-1033.
14. Gibson CM, Cannon CP, Daley WL, et al. TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation, 1996, 93(5): 879-888.
15. Poyraz E, Savaş G, Erdem A, et al. The mean corrected TIMI frame count could predict major adverse cardiovascular events in patients with coronary slow-flow phenomenon. Turk Kardiyol Dern Ars, 2022, 50(4): 250-255.
16. Ong P, Camici PG, Beltrame JF, et al. International standardization of diagnostic criteria for microvascular angina. Int J Cardiol, 2018, 250: 16-20.
17. 徐艺硕, 胡思宁, 贾海波, 等. 冠状动脉微循环侵入性诊疗用于急性 ST 段抬高型心肌梗死患者的研究进展. 中国介入心脏病学杂志, 2022, 30(5): 382-387.
18. Maznyczka AM, Oldroyd KG, McCartney P, et al. The potential use of the index of microcirculatory resistance to guide stratification of patients for adjunctive therapy in acute myocardial infarction. JACC Cardiovasc Interv, 2019, 12(10): 951-966.
19. Taqueti VR, Di Carli MF. Coronary microvascular disease pathogenic mechanisms and therapeutic options: JACC state-of-the-art review. J Am Coll Cardiol, 2018, 72(21): 2625-2641.
20. Maznyczka AM, Oldroyd KG, Greenwood JP, et al. Comparative significance of invasive measures of microvascular injury in acute myocardial infarction. Circ Cardiovasc Interv, 2020, 13(5): e008505.
21. 严颖, 王碧雲, 卫华. 冠状动脉微血管疾病影像学应用的研究进展. 中西医结合心脑血管病杂志, 2023, 21(7): 1246-1249.
22. 段天兵, 向定成. 急性心肌梗死后冠状动脉微循环障碍发生机制和诊治方法的研究进展. 中国循环杂志, 2019, 34(7): 722-725.
23. 王岚, 马玉良, 王伟民, 等. 心肌声学造影评估急性心肌梗死患者血运重建后冠状动脉微循环障碍的研究. 中国循环杂志, 2021, 36(10): 985-990.
24. Lam JH, Quah JX, Davies T, et al. Relationship between coronary microvascular dysfunction and left ventricular diastolic function in patients with chest pain and unobstructed coronary arteries. Echocardiography, 2020, 37(8): 1199-1204.
25. 张社芳, 王华, 王振华, 等. 超声造影对心肌微血管损伤的实验研究. 中国医学工程, 2022, 30(1): 17-20.
26. Ong P, Safdar B, Seitz A, et al. Diagnosis of coronary microvascular dysfunction in the clinic. Cardiovasc Res, 2020, 116(4): 841-855.
27. Everaars H, de Waard GA, Driessen RS, et al. Doppler flow velocity and thermodilution to assess coronary flow reserve: a head-to-head comparison with [¹⁵O]H₂O PET. JACC Cardiovasc Interv, 2018, 11(20): 2044-2054.
28. Al-Mallah MH, Nayfeh M, Alrifai M. The role of cardiac PET in diagnosis and prognosis of patients with ischemia with no obstructive coronary arteries (INOCA). Am Heart J Plus, 2024, 43: 100399.
29. Benenati S, Campo G, Seitun S, et al. Ischemia with non-obstructive coronary artery (INOCA): non-invasive versus invasive techniques for diagnosis and the role of #FullPhysiology. Eur J Intern Med, 2024, 127: 15-24.
30. Schulz-Menger J, Bluemke DA, Bremerich J, et al. Standardized image interpretation and post-processing in cardiovascular magnetic resonance - 2020 update: Society for Cardiovascular Magnetic Resonance (SCMR): Board of Trustees Task Force on Standardized Post-Processing. J Cardiovasc Magn Reson, 2020, 22(1): 19.
31. Patel AR, Salerno M, Kwong RY, et al. Stress cardiac magnetic resonance myocardial perfusion imaging: JACC review topic of the week. J Am Coll Cardiol, 2021, 78(16): 1655-1668.
32. Kotecha T, Martinez-Naharro A, Boldrini M, et al. Automated pixel-wise quantitative myocardial perfusion mapping by CMR to detect obstructive coronary artery disease and coronary microvascular dysfunction: validation against invasive coronary physiology. JACC Cardiovasc Imaging, 2019, 12(10): 1958-1969.
33. Bulluck H, Dharmakumar R, Arai AE, et al. Cardiovascular magnetic resonance in acute ST-segment-elevation myocardial infarction: recent advances, controversies, and future directions. Circulation, 2018, 137(18): 1949-1964.
34. Symons R, Pontone G, Schwitter J, et al. Long-term incremental prognostic value of cardiovascular magnetic resonance after ST-segment elevation myocardial infarction: a study of the collaborative registry on CMR in STEMI. JACC Cardiovasc Imaging, 2018, 11(6): 813-825.
35. Vora KP, Kumar A, Krishnam MS, et al. Microvascular obstruction and intramyocardial hemorrhage in reperfused myocardial infarctions: pathophysiology and clinical insights from imaging. JACC Cardiovasc Imaging, 2024, 17(7): 795-810.
36. Ibanez B, Aletras AH, Arai AE, et al. Cardiac MRI endpoints in myocardial infarction experimental and clinical trials: JACC Scientific Expert Panel. J Am Coll Cardiol, 2019, 74(2): 238-256.
37. 蔡宜婷, 邢浩然, 郝明辉, 等. STEMI 再灌注微血管损伤的心脏磁共振成像新进展. 中华心血管病杂志, 2022(12): 1237-1242.
38. Reinstadler SJ, Stiermaier T, Reindl M, et al. Intramyocardial haemorrhage and prognosis after ST-elevation myocardial infarction. Eur Heart J Cardiovasc Imaging, 2019, 20(2): 138-146.
39. Vyas R, Changal KH, Bhuta S, et al. Impact of intramyocardial hemorrhage on clinical outcomes in ST-elevation myocardial infarction: a systematic review and meta-analysis. J Soc Cardiovasc Angiogr Interv, 2022, 1(6): 100444.
40. Moon BF, Iyer SK, Hwuang E, et al. Iron imaging in myocardial infarction reperfusion injury. Nat Commun, 2020, 11(1): 3273.

West China Medical Journal

Progress in the development of mechanisms and assessment tools for coronary microvascular dysfunction after acute myocardial infarction

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