Non-invasive assessment of microvascular dysfunction in patients with microvascular angina

Caroline Jaarsma, Hans Vink, Judith van Haare, Sebastiaan C.A.M. Bekkers, Bart D. van Rooijen, Walter H. Backes, Joachim E. Wildberger, Harry J. Crijns, Jurgen van Teeffelen, Simon Schalla
International Journal of Cardiology



We aimed to evaluate the microvascular function in patients with microvascular angina (MVA) by assessing 1) the endothelial glycocalyx barrier properties using sublingual microscopy, and 2) the myocardial perfusion reserve using cardiovascular magnetic resonance (CMR) imaging.


Sublingual microscopy was performed in 13 MVA patients (angina pectoris, ST-depression on treadmill testing, normal coronary angiogram) and compared with 2 control groups of 13 volunteers and 14 patients with known obstructive coronary artery disease (CAD). To test the glycocalyx-mediated microvascular responsiveness, the erythrocyte perfused boundary region (PBR) was assessed at baseline and after nitroglycerin challenge.


The baseline PBR of MVA patients was similar to controls with CAD (p = 0.72), and larger than in volunteers (p = 0.02). Only the volunteers demonstrated a significant increase in PBR after nitroglycerin (p = 0.03). In the 13 MVA patients, adenosine stress CMR perfusion imaging was performed. Although a significant increase in myocardial perfusion was observed in both the subendocardium and subepicardium during stress, the subendocardial perfusion reserve was significantly lower (p = 0.02). The PBR responsiveness of the sublingual microvasculature showed a strong correlation with the transmural myocardial perfusion reserve (r = 0.86, p < 0.001).


Patients with MVA can be characterized by microvascular glycocalyx dysfunction using sublingual microscopy. The strong correlation between sublingual PBR responsiveness and myocardial perfusion reserve suggests that the glycocalyx may play an important role in the regulation of microvascular volume for myocardial perfusion and supports the concept of impaired glycocalyx barrier properties in MVA.