С.П. Соловей
Республиканский научно-практический центр «Кардиология», г. Минск
Стенокардия является одним из наиболее частых симптомов ишемической болезни сердца (ИБС). Проведение коронароангиографического обследования у значительной части пациентов со стенокардией и признаками ишемии миокарда не обнаруживает обструктивных атеросклеротических изменений коронарных артерий (КА). Самостоятельными или дополнительными механизмами ишемии могут быть микрососудистая дисфункция и эпикардиальный коронарный вазоспазм. Клиническая форма ИБС, в основе которой лежит ишемия, вызванная дисфункцией коронарных сосудов в отсутствии обструктивных изменений, относительно недавно получила определение INOCA (Ischaemia with No Obstructive Coronary Artery Disease). Понятие INOCA объединяет две разновидности стенокардии – микрососудистую и вазоспастическую. Лежащие в основе INOCA коронарные вазомоторные расстройства имеют как различные патофизиологические механизмы, так и локализацию в самой сосудистой системе коронарного кровообращения. Клинически наиболее важными вазомоторными нарушениями являются эпикардиальный и микрососудистый вазоспазм, нарушение микрососудистой вазодилатации. В статье изложен краткий обзор механизмов регуляция коронарного кровотока в физиологических условиях и сосудистой дисфункции при необструктивном атеросклеротическом поражении.
ключевые слова: необструктивное поражение, микрососудистая дисфункция, эпикардиальный вазоспазм, микрососудистая стенокардия, вазоспастическая стенокардия

для цитирования: С.П. Соловей. Стенокардия без обструктивного поражения коронарных артерий (часть 1). Патофизиологические основы развития. Неотложная кардиология и кардиоваскулярные риски, 2021, Т. 5, № 2, С. 1274–.1283

Angina without obstructive lesion coronary arteries (part 1). Pathophysiological aspects of development
S.Р. Solovey
Angina pectoris is one of the most common symptoms of ischemic heart disease (IHD). Coronary angiography in a significant part of patients with angina pectoris and signs of myocardial ischemia does not reveal obstructive atherosclerotic changes in the coronary arteries. Independent or additional mechanisms of ischemia can be microvascular dysfunction and epicardial coronary vasospasm. The clinical form of ischemic heart disease, which is based on ischemia caused by dysfunction of the coronary vessels in the absence of obstructive changes, has recently received the definition of INOCA (Ischaemia with No Obstructive Coronary Artery Disease). The concept of INOCA comprises two types of angina pectoris – microvascular and vasospastic. The underlying INOCA coronary vasomotor disorders have both different pathophysiological mechanisms and localization in the vascular system of the coronary circulation itself. Clinically the most important vasomotor disorders are epicardial and microvascular vasospasm, impaired microvascular vasodilation. The article provides a brief overview of the mechanisms of regulation of coronary blood flow under physiological conditions and vascular dysfunction in non-obstructive atherosclerotic lesions.
keywords: non-obstructive lesion, microvascular dysfunction, epicardial vasospasm, microvascular angina, vasospastic angina

for references: S.Р. Solovey. Angina without obstructive lesion coronary arteries (part 1). Pathophysiological basis of development. Neotlozhnaya kardiologiya i kardiovaskulyarnye riski [Emergency cardiology and cardiovascular risks], 2021, vol. 5, no. 2, pp. 1274–1283

References
1. Reeh J., Therming C.B., Heitmann M., Hojberg S., Sorum C., Bech J., Husum D., Dominguez H., Sehestedt T., Hermann T., Hansen K.W., Simonsen L., Galatius S., Prescott E. Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina. Eur Heart J, 2019, vol. 40, no 18, pp. 1426–1435. doi: 10.1093/eurheartj/ehy806.
2. Patel M.R., Peterson E.D., Dai D., Brennan J.M., Redberg R.F., Anderson H.V., Brindis R.G., Douglas P.S. Low diagnostic yield of elective coronary angiography. N Engl J Med, 2010, vol. 362, pp. 886–95. doi: 10.1056/NEJMoa0907272.
3. Shaw L.J., Shaw R.E., Merz C.N., Brindis R.G., Klein L.W., Nallamothu B., Douglas P.S., Krone R.J., McKay C.R., Block P.C., Hewitt K., Weintraub W.S., Peterson E.D. Impact of ethnicity and gender differences on angiographic coronary artery disease prevalence and in-hospital mortality in the American College of Cardiology-National Cardiovascular Data Registry. Circulation, 2008, vol. 117, pp. 1787–1801. doi: 10.1161/CIRCULATIONAHA.107.726562.
4. Levitt K., Guo H., Wijeysundera H.C., Ko D.T., Natarajan M.K., Feindel M.C., Kingsbury K., Cohen E.A., Tu J.V. Predictors of normal coronary arteries at coronary angiography. Am Heart J, 2013, vol. 166, no. 4, pp. 694-700. doi: 10.1016/j.ahj.2013.07.030.
5. Johnston N., Schenck-Gustafsson K., Lagerqvist B. Are we using cardiovascular medications and coronary angiography appropriately in men and women with chest pain? Eur Heart J, 2011, vol. 32, pp. 1331–61336. doi: 10.1093/eurheartj/ehr009.
6. Jespersen L, Hvelplund A., Abildstrom S.Z., Pedersen F., Galatius S., Madsen J.K., Jorgensen E., Kelbaek H., Prescott E. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J, 2012, vol. 33, pp. 734–744. doi: 10.1093/eurheartj/ehr331.
7. Knuuti J., Wijns W., Saraste A., Capodanno D., Barbato E., Funck-Brentano C., Prescott E., Storey R.F., Deaton C., Cuisset T., Agewall S., Dickstein K., Edvardsen T., Escaned J., Gersh B.J., Svitil P., Gilard M., Hasdai D., Hatala R., Mahfoud F., Masip J., Muneretto C., Valgimigli M., Achenbach S., Bax J.J.; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur Heart J, 2020, vol. 41, no. 3, pp. 407-477. doi: 10.1093/eurheartj/ehz425.
8. Alekyan B.G., Grigoryan A.M., Staferov A.V., Karapetyan N.G. Rentgenendovaskulyarnaya diagnostika i lechenie zabolevanij serdca i sosudov v Rossijskoj Federacii - 2017 god [Endovascular diagnostics and treatment in the Russian Federation (2017)]. Endovaskulyarnaya Khirurgiya, 2018, vol. 5, no. 2, pp. 93–240. doi: 10.24183/2409-4080-2018-5-2-93-240. (in Russan).
9. Korok E.V., Sumin A.N., Sinkov M.A., Nagirnyak O.A., Chichkova T. Yu., Barbarash L. S. Chastota vyyavleniya intaktnyh koronarnyh arterij v zavisimosti ot pokazanij dlya planovoj koronarnoj angiografii [The prevalence of intact coronary arteries in relation with indication for scheduled coromary arteriography]. Rossijskij kardiologicheskij zhurnal, 2016, vol. 21, no. 2, pp. 52–59. doi: 10.15829/1560-4071-2016-2-52-59. (in Russian).
10. Wang Z.J., Zhang L.L., Elmariah S., Han H.Y., Zhou Y.J. Prevalence and Prognosis of Nonobstructive Coronary Artery Disease in Patients Undergoing Coronary Angiography or Coronary Computed Tomography Angiography: A Meta-Analysis. Mayo Clin Proc, 2017, vol. 92, no 3, pp. 329– 346. doi: 10.1016/j.mayocp.2016.11.016.
11. Reeh J., Therming C.B., Heitmann M., Hojberg S., Sorum C., Bech J., Husum D, Dominguez H, Sehestedt T., Hermann T., Hansen K.W., Simonsen L., Galatius S., Prescott E. Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina. Eur Heart J, 2019, vol. 40, no 18, pp. 1426–1435. doi: 10.1093/eurheartj/ehy806.
12. Marzilli M., Huqi A., Morrone D. Persistent angina: the Araba Phoenix of cardiology. Am J Cardiovasc Drugs, 2010, vol. 10, Suppl. 1, pp. 27–32. doi: 10.2165/1153643-S0-000000000-00000.
13. Ford T.J., Berry C. Angina: contemporary diagnosis and management. Heart, 2020, vol. 106, no. 5, pp. 387-398. doi: 10.1136/heartjnl-2018-314661.
14. Crea F., Camici P. G., Bairey Merz C.N. Coronary microvascular dysfunction: an update. Eur. Heart J, 2013, vol. 35, pp. 1101–1111. doi: 10.1093/eurheartj/eht513.
15. Crea F., Camici P.G., Bairey Merz C.N. Coronary microvascular dysfunction: an update. Eur Heart J, 2014, vol. 35, no. 17, pp. 1101–1111. doi: 10.1093/eurheartj/eht513.
16. Khuddus M.A., Pepine C.J., Handberg E.M., Bairey Merz C.N., Sopko G., Bavry A.A., Denardo S.J., McGorray S.P., Smith K.M., Sharaf B.L., Nicholls S.J., Nissen S.E., Anderson R.D. An intravascular ultrasound analysis in women experiencing chest pain in the absence of obstructive coronary artery disease: a substudy from the National Heart, Lung and Blood Institute-Sponsored Women’s Ischemia Syndrome Evaluation (WISE). J Interv Cardiol, 2010, vol. 23, pp. 511–519. Doi: 10.1111/j.1540-8183.2010.00598.x.
17. Bairey Merz C.N., Pepine C.J., Walsh M.N., Fleg J.L., Fleg J.L., Camici P.G., Chilian W.M., Clayton J.A., Cooper L.S., Crea F., Di Carl M., Douglas P.S., Galis Z.S., Gurbel P., Handberg E.M., Hasan A., Hill J.A., Hochman J.S., Iturriaga E., Kirby R., Levine G.N., Libby P., Lima J., Mehta P., Desvigne-Nickens P., Olive M., Pearson G.D., Quyyumi A.A., Reynolds H., Robinson B., Sopko G., Taqueti V., Wei J., Wenger N. Ischemia and No Obstructive Coronary Artery Disease (INOCA): Developing Evidence-Based Therapies and Research Agenda for the Next Decade. Circulation, 2017, vol. 135, no. 11, pp. 1075-1092. doi: 10.1161/ CIRCULATIONAHA.116.024534.
18. Hanson C. A., Lu E., Ghumman S. S., Ouellette M.L., Löffler A.I., Beller G.A., Bourque J.M. Long-term outcomes in patients with normal coronary arteries, nonobstructive, or obstructive coronary artery disease on invasive coronary angiography. Clin Cardiol, 2021, vol. 44, no. 9, pp. 1286-1295. doi: 10.1002/clc.23686.
19. Tomanek R.J. Structure-Function of the Coronary Hierarchy: Coronary Vasculature. New York, Springer, 2013, pp. 59–81. doi: 10.1007/978-1-4614-4887-7.
20. Deussen A., Ohanyan V., Jannasch A., Yin L., Chilian W. Mechanisms of metabolic coronary flow regulation. J Mol Cell Cardiol, 2012, vol. 52, pp. 794–801. doi: 10.1016/j.yjmcc.2011.10.001.
21. Vancheri F., Giovanni L., Vancheri S., Henein М. Coronary Microvascular Dysfunction. J Clin Med, 2020, vol. 9, no. 9, pp. E2880. doi: 10.3390/jcm9092880.
22. Bing R.J., Hammond M.M., Handelsman J.C., et al. The measurement of coronary blood flow, oxygen consumption, and efficiency of the left ventricle in man. Am Heart J, 1949, vol. 38, no. 1, pp. 1-24. doi: 10.1016/0002-8703(49)90788-7.
23. Chilian W.M. Coronary microcirculation in health and disease. Summary of an NHLBI workshop. Circulation, 1997, vol. 95, pp. 522-528. doi: 10.1161/01.CIR.95.2.522.
24. Kunadian V., Chieffo A., Camici P.G., Colin Berry, Escaned J., Maas A. H E M, Prescott E., Karam N., Appelman Y., Fraccaro C., Buchanan G.L., Manzo-Silberman S., Al-Lamee R., Regar E., Lansky A., Abbott J.D., Badimon L., Duncker D.J., Mehran R., Capodanno D., Baumbach A. An EAPCI expert consensus document on ischaemia with non-obstructive coronary arteries in collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation endorsed by Coronary Vasomotor Disorders International Study Group. Eur.Heart J, 2020, vol. 41, no. 37, pp. 3504–3520. doi. 10.1093/eurheartj/ehaa503.
25. Duncker D.J., Koller A., Merkus D., Canty J.M.Jr. Regulation of coronary blood flow in health and ischemic heart disease. Prog Cardiovasc Dis, 2015, vol. 57, pp. 409–422. doi: 10.1016/j.pcad.2014.12.002.
26. Ong, P., Athanasiadis A., Borgulya G., Mahrholdt H., Kaski J.C., Sechtem U. High Prevalence of a Pathological Response to Acetylcholine Testing in Patients with Stable Angina Pectoris and Unobstructed Coronary Arteries: The ACOVA Study (Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries). J Am Coll Cardiol, 2012, vol. 59, no. 7, pp. 655–662. doi: 10.1016/j.jacc.2011.11.015.
27. Pries A.R., Badimon L., Bugiardini R., Camici P.G., Dorobantu M., Duncker D.J., Escaned J., Koller A., Piek J.J., de Wit C. Coronary vascular regulation, remodelling, and collateralization: mechanisms and clinical implications on behalf of the working group on coronary pathophysiology and microcirculation. Eur Heart J, 2015, vol. 36, no. 45, pp. 3134–3146. doi: 10.1093/eurheartj/ehv100.
28. Konst R.E., Guzik T.J., Kaski J.-C., Maas A.H E M, Elias-Smale S.E. The pathogenic role of coronary microvascular dysfunction in the setting of other cardiac or systemic conditions. Cardiovasc Res, 2020, vol. 116, no. 4, pp. 817–828. doi: 10.1093/cvr/cvaa009.
29. Kachur S., Morera R., Schutter A.D., Lavie C.J. Cardiovascular risk in patients with prehypertension and the metabolic syndrome. Curr Hypertens Rep, 2018, vol. 20, no. 2, pp. 15. doi: 10.1007/s11906-018-0801-2.
30. Taqueti V.R. Coronary microvascular dysfunction in vasospastic angina: provocative role for the microcirculation in macrovessel disease prognosis. J Am Coll Cardiol, 2019, vol. 74, no. 19, pp. 2361–2364. doi: 10.1016/j.jacc.2019.09.042.
31. Shimokawa H. 2014 Williams Harvey Lecture: importance of coronary vasomotion abnormalities-from bench to bedside. Eur Heart J, 2014, vol. 35, pp. 3180-3193. doi:10.1093/eurheartj/ehu427.
32. Camici P.G., Crea F. Coronary microvascular dysfunction. N Engl J Med, 2007, vol. 356, no. 8, pp. 830-840. doi: 10.1056/NEJMra061889.
33. Badimon L., Bugiardini R., Cenko E., Cubedo J., Dorobantu M., Duncker D.J., Estruch R., Milicic D., Tousoulis D., Vasiljevic Z., Vilahur G., de Wit C., Koller A. Position paper of the European Society of Cardiology-working group of coronary pathophysiology and microcirculation: obesity and heart disease. Eur Heart J, 2017, vol. 38, no. 25, pp. 1951–1958. doi: 10.1093/eurheartj/ehx181.
34. Hung M.J., Cherng W.J., Cheng C.W., Li L.F. Comparison of serum levels of inflammatory markers in patients with coronary vasospasm without significant fixed coronary artery disease versus patients with stable angina pectoris and acute coronary syndromes with significant fixed coronary artery disease. Am J Cardiol, 2006, vol. 97, pp. 1429-1434. doi: 10.1016/j.amjcard.2005.12.035.
35. Camici P.G., d’Amati G., Rimoldi O. Coronary microvascular dysfunction: mechanisms and functional assessment. Nat Rev Cardiol, 2015, vol. 12, pp. 48–62. doi: 10.1038/nrcardio.2014.160.
36. Ford T.J., Berry C. How to Diagnose and Manage Angina Without Obstructive Coronary Artery Disease: Lessons from the British Heart Foundation CorMicA Trial. Interv Cardiol, 2019, vol. 14, no. 2, pp. 76–82. doi: 10.15420/icr.2019.04.R1.
37. Taqueti V.R., Di Carli M.F. Coronary Microvascular Disease Pathogenic Mechanisms and Therapeutic Options: JACC State-of-the-Art Review. J Am Coll Cardiol, 2018, vol. 72, no. 21, pp. 2625-2641. doi: 10.1016/j.jacc.2018.09.042.
Поступила 19.07.2021
Формат файла: pdf (725.45 Кб)