Half of the heart patients had normal test results. A breakthrough in diagnostics

Until recently, when the availability of microcirculation diagnostics was very limited (and practically unavailable for Polish patients), up to 45 percent. patients with chest pain had normal coronary angiography. In a way, this result said: “Your vessels are healthy and you are in pain…. basically, we do not know what exactly and why – explains the cardiologist, dr hab. n. med. Łukasz Kołtowski.

1. Until recently, when the availability of diagnostics of coronary microcirculation was very limited (and for Polish patients it was virtually unavailable), up to 45 percent. patients with chest pain had normal coronary angiography
2. However, many doctors suspected that the lack of abnormalities as a result of this examination was not the whole truth about their patient
3. Some doctors suggested that the problem was excessive pain perception by patients – explains Dr. Kołtowski
4. You can find more such stories on the TvoiLokony home page

Doctor, what is coronary microcirculation – an issue that has recently received more and more attention in the field of invasive cardiology?

Dr hab. n. med. Łukasz Kołtowski: Simply put, coronary microcirculation is part of the blood vessel system of the heart muscle. It is defined as a network of arterial vessels less than 0,45 mm in diameter. Coronary microcirculation is important because it is responsible for up to 95 percent. regulation of blood flow through the heart muscle. It has the function of supplying blood, but also the function of regulating the flow, so thanks to it the heart muscle constantly receives the right amount of blood necessary for its work.

The patient should know why he gets sick

In which areas is the functional assessment of coronary microcirculation applicable?

There are a triad of reasons why we want to evaluate the coronary microcirculation as interventional cardiologists. Firstly, diagnosis, secondly, prognosis, and thirdly, treatment. Each of these elements is equally important. Beginning with the diagnosis: we believe that patients simply deserve an answer to the question of why they are sick and why they have specific ailments.

Is it not always possible to answer this question?

Exactly. Please imagine that until recently, when the availability of microcirculation diagnostics was very limited (and for Polish patients it was virtually unavailable), up to 45 percent. patients with chest pain had normal coronary angiography. In a way, this result said: “Dear Patient, Your vessels are healthy and you are in pain…. basically we don’t know what exactly and why. Maybe it’s pains from the spine? Or maybe you have some kind of over-image of your pain? ” In such a situation, some patients were even treated with antidepressants and anxiolytics.

This is shocking!

However, please remember: the coronary examination did not show any abnormalities. So, on what basis was it possible to diagnose cardiovascular disease? Nevertheless, many doctors suspected that the correct result of coronary angiography was not the whole truth about their patient. Both the doctor and the patient felt that the unexplained ailments had their most physical cause. Let us emphasize: the diagnosis is very important for the patients themselves. Many patients tell us that they just want to know what is wrong with them (even if their condition could not be treated effectively, although in the case of ischemic disease it is possible). The patient asks: what’s wrong with me? What is behind my ailments? This is a legitimate question and every patient deserves a reliable answer.

How does being able to answer this question affect prognosis?

When assessing the prognosis, as doctors, we want to understand whether our patient will live “happily and long” and, in principle, after an ad hoc intervention, he can be released home, or perhaps on his way in the coming months or years, an increased cardiovascular risk should be expected. . This risk is defined as: heart attack, stroke, re-coronary angiography and, unfortunately, death. We know that those patients who have a worse prognosis, who have a higher risk of complications, should receive closer care. This means that we will invite these patients for control visits to the clinic more often. We will be more alert to the symptoms they report, destabilization and new symptoms. In patients with ischemia of microcirculation etiology, the prognosis is several times worse than in a patient who is not diagnosed with this disease or simply does not have this disease. Such a combination of the two worst variants of microcirculation disease increases the risk of death, stroke and heart attack up to six times. The last thing is treatment.

Modern diagnostics is standard

Won’t the therapeutic management of patients with microcirculation disorders be essentially the same?

Not necessarily, because the assessment of the microcirculation phenotype allows us to choose drugs suitable for a specific patient – we have a chance to apply personalized therapy, which is generally the most effective.

What do the scientific guidelines say about the functional assessment of coronary microcirculation?

The guidelines based on the available randomized prospective trials in which patients were diagnosed and then treated have changed over the years to introduce active functional microcirculation diagnosis in patients with chest pain who have normal coronary angiography into the guidelines for cardiac management ( in the sense of the lack of confirmation of significant changes in the coronary arteries). Therefore, today the diagnosis of microcirculation is simply a standard of care, included in the recommendations of the European and Polish Cardiac Society regarding the diagnosis of chronic coronary syndrome.

Is Polish clinical practice keeping up with the guidelines? The Doctor mentioned that the functional assessment of the coronary microcirculation is also available for patients in our country.

Until recently, microcirculation diagnostics in Poland was available only as part of clinical trials. Since the method of microcirculation assessment was a method based mainly on an ultrasound – Doppler probe, inserted into the coronary artery, very difficult to use, it was time-consuming, and the probe itself was very expensive and therefore simply unavailable in practice. The functional assessment of the coronary microcirculation was performed only by researchers who investigated the physiology and pathophysiology of the coronary circulation as part of scientific studies. However, for several years we have available in Poland reimbursed tools for the functional assessment of epicardial arteries, the so-called partial flow assessment, commonly: FFR. The latest breakthrough is the probes used for the functional evaluation of epicardial arteries, which were equipped with temperature sensors in a basically standard way. As a result, using the same probes, but connected to the console with different software, we are also able to assess the microcirculation.

Microcirculation study – a revolution in cardiology

The technological revolution resulted from the evolutionary development of diagnostic methods?

The popularization of microcirculation diagnostics is actually due to the fact that the tools we already know and use in our patients to assess the epicardial sections have been enriched with new functions. In fact, we are talking about the last few years, when the first centers in Poland offered microcirculation diagnostics to patients – as the first center of the Collegium Medicum of the Jagiellonian University. We, as the XNUMXst Department and Clinic of Cardiology of the Medical University of Warsaw, started offering this procedure to patients. It is worth noting that the so-called entry barrier is not high in the scope of this study. Patient qualification is very important. It is also worth educating in this area. We do it as part of the newly created educational initiative “IC You”, addressed to young adepts of interventional cardiology.

Is the functional assessment of the coronary microcirculation an element that significantly extends the time of coronary diagnosis?

In fact, the diagnosis of microcirculation is an extension of the coronary angiography protocol. It does not require any special, additional preparation of the patient. It can therefore be the next step in this procedure: after the coronary angiography is performed, we can proceed to the assessment of microcirculation from the same access and thanks to the use of the same catheters. The time is getting longer, it’s true – probably by several minutes per procedure. Performing the evaluation of the microcirculation resistance and the flow of the coronary flow reserve indicator itself takes probably a few minutes. A little longer, if we additionally want to perform a provocation test with acetylcholine, because the preparation of the drug takes some time. In my opinion, each patient qualified for functional assessment using the FFR method should be diagnosed with a protocol that includes the assessment of microcirculation parameters. When our patient is on the table anyway and we have the probe in our hand, it seems to me that the functional diagnostics of microcirculation is absolutely obligatory. There is no doubt that it is worth doing, you just have to remember it.

It is worth knowing about this possibility and it can be used – is it really enough?

This, of course, is not quite literally that simple. The software necessary for the study is probably not available in every laboratory in Poland. Its provision is associated with specific costs. Another thing: it would be worth extending the catalog of providing functional assessment of coronary arteries to include the assessment of microcirculation. Today, it is a procedure “embedded” in the reimbursed FFR procedure. If the National Health Fund pays for the implementation of the FFR, we can make the proverbial additional three clicks and settle everything within one test, but it would be good if the microcirculation assessment was a coded procedure and that the centers had no doubts here in terms of settlements with the Fund. Finally, it is worth noting that the centers that today offer microcirculation diagnostics are open to admitting and diagnosing patients. As part of the Association of Cardiovascular Interventions of the Polish Cardiac Society, a microcirculation register was created. The purpose of this register is to collect medical data on the occurrence and characteristics of patients with microcirculation dysfunctions so that in the Polish population we can assess them more precisely and describe them better, and then be able to present the effects of treatment of these patients in the future on the Polish data.

Thank you for the conversation.