Michel Zeitouni; Ghilas Rahoual; Niki Procopi; Frederic Beaupré; Maxime Michon; Clélia Martinez; David Sulman; Paul Guedeney; Nadjib Hammoudi; Eric Vicaut; Stéphane Hatem; Mathieu Kerneis; Johanne Silvain; Gilles Montalescot; for the ACTION Group

doi:10.4244/EIJ-D-24-00247

Changes in absolute coronary flow and microvascular resistance during exercise in patients with ANOCA

Michel Zeitouni¹, MD, PhD; Ghilas Rahoual¹, MD; Niki Procopi¹, MD; Frederic Beaupré¹, MD; Maxime Michon¹, MD; Clélia Martinez¹, RN; David Sulman¹, MD; Paul Guedeney¹, MD; Nadjib Hammoudi¹, MD, PhD; Eric Vicaut², MD, PhD; Stéphane Hatem¹, MD, PhD; Mathieu Kerneis¹, MD, PhD; Johanne Silvain¹, MD, PhD; Gilles Montalescot¹, MD, PhD; for the ACTION Group

Abstract

Background: Whether saline-induced hyperaemia captures exercise-induced coronary flow regulation remains unknown.

Aims: Through this study, we aimed to describe absolute coronary flow (Q) and microvascular resistance (Rμ) adaptation during exercise in participants with angina with non-obstructive coronary artery disease (ANOCA) and to explore the correlations between saline- and exercise-derived coronary flow reserve (CFR) and microvascular resistance reserve (MRR).

Methods: Rμ, Q, CFR and MRR were assessed in the left anterior descending artery using continuous thermodilution with saline infusion at 10 mL/min (rest), 20 mL/min (hyperaemia) and finally at a 10 mL/min infusion rate during stress testing with a dedicated supine cycling ergometer. An incremental workload of 30 watts every two minutes was applied. A saline-derived CFR (CFR_saline) cutoff <2.5 was used to identify coronary microvascular dysfunction (CMD).

Results: CFR_saline-defined CMD was observed in 53.3% of the participants (16/30). While cycling, these patients less of an ability to increase Q (7 [interquartile range [IQR] 30.5-103.0] vs 21 [IQR 5.8-45.0] mL/min/30 watts; p=0.01) due to a smaller decrease of Rμ (109 {IQR 32-286} vs 202 [IQR 102-379] Wood units [WU]/30 watts; p<0.01) as compared with the group with normal CFR_saline. In the overall population, CFR_saline and exercise-derived CFR (CFR_exercise) were 2.70±0.90 and 2.85±1.54, respectively, with an agreement classification of 83.3%. A good correlation between saline and exercise techniques for both CFR (r=0.73; p<0.0001) and MRR (r=0.76; p<0.0001) was observed. Among participants with normal CFR_saline, 28.7% (4/14) had an impaired CFR_exercise <2.5 at the peak of exercise due to a moderate and late decrease of Rμ.

Conclusions: Saline-induced hyperaemia provided a valid surrogate for exercise physiology independently of the absolute level of CFR and MRR, although exercise provided more granularity to evaluate adaptation among participants with exercise-related CMD.

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