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“Meeting Point” of Cardiology, Rheumatology and Endocrinology

Eur J Clin Invest 2021 Dec 22;e13737.
Coronary microvascular disease: The “Meeting Point” of Cardiology, Rheumatology and Endocrinology
George Markousis-Mavrogenis 1, Flora Bacopoulou 2, Clio Mavragani 3, Paraskevi Voulgari 4, Genovefa Kolovou 1 5, George D Kitas 5, George P Chrousos 2, Sophie I Mavrogeni 1

Abstract
Background: Exertional chest pain/dyspnea or chest pain at rest are the main symptoms of coronary artery disease (CAD), which are traditionally attributed to insufficiency of the epicardial coronary arteries. However, 2/3 of women and 1/3 of men with angina and 10% of patients with acute myocardial infarction have no evidence of epicardial coronary artery stenosis in X-ray coronary angiography. In these cases, coronary microvascular disease (CMD) is the main causative factor.
Aims: To present the pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology.
Materials-methods: The pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology was evaluated. It includes impaired microvascular vasodilatation, which leads to inability of the organism to deal with myocardial oxygen needs and, hence, development of ischemic pain. CMD, observed in inflammatory autoimmune rheumatic and endocrine/metabolic disorders, brings together Cardiology, Rheumatology and Endocrinology. Causative factors include persistent systemic inflammation and endocrine/metabolic abnormalities influencing directly the coronary microvasculature. In the past, the evaluation of microcirculation was feasible only with the use of invasive techniques, such as coronary flow reserve assessment. Currently, the application of advanced imaging modalities, such as cardiovascular magnetic resonance (CMR), can evaluate CMD non-invasively and without ionizing radiation.
Results: CMD may present with a variety of symptoms with 1/3 to 2/3 of them expressed as typical chest pain in effort, more commonly found in women during menopause than in men. Atypical presentation includes chest pain at rest or exertional dyspnea, but post exercise symptoms are not uncommon. The treatment with nitrates is less effective in CMD, because their vasodilator action in coronary micro-circulation is less pronounced than in the epicardial coronary arteries.
Discussion: Although both classic and new medications have been used in the treatment of CMD, there are still many questions regarding both the pathophysiology and the treatment of this disorder. The potential effects of anti-rheumatic and endocrine medications on the evolution of CMD need further evaluation.
Conclusion: CMD is a multifactorial disease leading to myocardial ischemia/fibrosis alone or in combination with epicardial coronary artery disease. Endothelial dysfunction/vasospasm, systemic inflammation, and/or neuroendocrine activation may act as causative factors and bring Cardiology, Rheumatology and Endocrinology together. Currently, the application of advanced imaging modalities, and specifically CMR, allows reliable assessment of the extent and severity of CMD. These measurements should not be limited to “pure cardiac patients”, as it is known that CMD affects the majority of patients with autoimmune rheumatic and endocrine/metabolic disorders.
Keywords: Cushing syndrome; autoimmune rheumatic diseases; cardiovascular magnetic resonance; coronary flow reserve; diabetes mellitus; microvascular coronary artery disease; thyroid disease.

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