What is the treatment for microvascular dysfunction, especially in women?

Treatment for Microvascular Dysfunction in Women

For women with microvascular coronary dysfunction (MCD), treatment should include statins and angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARBs) at maximally tolerated doses, along with antianginal therapy tailored to symptom relief. 1

Diagnosis and Risk Assessment

• Microvascular coronary dysfunction (MCD) presents with the triad of persistent chest pain, ischemic changes on stress testing, and no obstructive coronary artery disease on cardiac catheterization 2
• MCD is more prevalent in women and carries a 2.5% annual risk of adverse cardiac events including myocardial infarction, stroke, heart failure, and death 2
• Coronary reactivity testing (CRT) is the gold standard diagnostic test, using acetylcholine, adenosine, and nitroglycerin to assess endothelial-dependent and independent microvascular function 2
• Women with any positive cardiac biomarker (CRP, BNP, troponin) benefit from invasive therapy, while those without elevated biomarkers do better with a conservative approach 3

Pharmacological Treatment

First-Line Therapy

• High-intensity statins combined with ACE inhibitors or ARBs (if ACE-I intolerant) at maximally tolerated doses improve angina, stress testing results, myocardial perfusion, and coronary microvascular function 1
• ACE inhibitors should be used in women with clinical evidence of heart failure, left ventricular ejection fraction ≤40%, or diabetes mellitus (Class I, Level A) 3
• If ACE inhibitors are not tolerated, ARBs should be substituted (Class I, Level B) 3

Antianginal Therapy

• Beta-blockers should be used for symptom control, especially in women with prior MI, acute coronary syndrome, or left ventricular dysfunction (Class I, Level A) 3
• Calcium channel blockers are effective for symptom relief in microvascular dysfunction 2
• Nitrates may be used for acute symptom relief, though their effectiveness can be variable in MCD 2
• Ranolazine can be considered for persistent angina despite other antianginal medications 2

Additional Pharmacotherapy

• Low-dose aspirin (75-325 mg/day) should be used in high-risk women unless contraindicated (Class I, Level A) 3
• If aspirin is not tolerated, clopidogrel should be substituted (Class I, Level B) 3
• Consider niacin or fibrate therapy when HDL-C is low or non-HDL-C is elevated after LDL-C goal is reached (Class IIa, Level B) 3

Lifestyle Modifications

• A comprehensive risk-reduction regimen should be recommended, including cardiovascular rehabilitation or a physician-guided exercise program (Class I, Level A) 3
• Diet should be rich in fruits, vegetables, whole grains, and fish; limit saturated fat to <7% of energy, cholesterol to <300 mg/day, and sodium to <2.3 g/day (Class I, Level B) 3
• Weight management through physical activity and appropriate caloric intake to maintain BMI between 18.5-24.9 kg/m² and waist circumference <35 inches (Class I, Level B) 3
• Smoking cessation counseling and support 2

Additional Treatment Options for Refractory Symptoms

• Tricyclic antidepressants may help manage persistent chest pain 2
• Enhanced external counterpulsation can improve symptoms in selected patients 2
• Spinal cord stimulation may be considered for severe, refractory angina 2

Treatment Goals and Monitoring

• Aim for LDL-C <100 mg/dL (or <70 mg/dL in very high-risk women) (Class I, Level A/B) 3
• Target HDL-C >50 mg/dL, triglycerides <150 mg/dL, and non-HDL-C <130 mg/dL (Class I, Level B) 3
• For diabetic patients, target HbA1c <7% if achievable without significant hypoglycemia (Class I, Level C) 3
• Blood pressure goal <130/80 mmHg for those with chronic kidney disease or diabetes; <140/90 mmHg for others 3

Special Considerations

• Hormone therapy and selective estrogen-receptor modulators (SERMs) should not be used for prevention of cardiovascular disease (Class III, Level A) 3
• Consider screening for depression in women with coronary heart disease and refer/treat when indicated (Class IIa, Level B) 3
• Patients with microvascular dysfunction often receive false reassurance despite having ischemic heart disease because of the lack of obstructive coronary artery disease 4