What is the management plan for microvascular dysfunction in women?

Management of Microvascular Dysfunction in Women

The management of microvascular dysfunction in women should focus on a combination of pharmacological therapy, lifestyle modifications, and diagnostic testing to improve symptoms, quality of life, and reduce cardiovascular events. 1

Diagnosis and Assessment

• For women with persistent stable chest pain and nonobstructive coronary artery disease (CAD), invasive coronary function testing is reasonable to diagnose coronary microvascular dysfunction and enhance risk stratification 1
• Stress PET myocardial perfusion imaging with myocardial blood flow reserve (MBFR) measurement is recommended to diagnose microvascular dysfunction 1
• Stress cardiac MRI with MBFR measurement is reasonable to improve diagnosis and estimate risk of major adverse cardiovascular events 1
• Stress echocardiography with coronary flow velocity reserve measurement may be reasonable for diagnosis and risk assessment 1

Pharmacological Treatment

• ACE inhibitors should be used as first-line therapy in women with microvascular dysfunction, particularly those with clinical evidence of heart failure, left ventricular ejection fraction ≤40%, or diabetes mellitus 1, 2
• If ACE inhibitors are not tolerated, ARBs should be substituted 1, 2
• Beta-blockers are effective in reducing episodes of chest discomfort and should be used for symptom control 1, 3
• Calcium channel blockers have been found to be effective in reducing the frequency of chest pain episodes 1, 3
• Low-dose aspirin (75-325 mg/day) should be used in high-risk women unless contraindicated 1, 2
• Statins should be used to treat microvascular endothelial dysfunction and reduce cardiovascular risk 3, 4
• Consider niacin or fibrate therapy when HDL-C is low or non-HDL-C is elevated after LDL-C goal is reached 1, 2
• Nitrates provide benefit in approximately half of patients with microvascular dysfunction 1
• Ranolazine may be considered for symptom management in women with persistent angina 3

Lifestyle Modifications

• A comprehensive risk-reduction regimen should be implemented, including cardiovascular rehabilitation or a physician-guided exercise program 1, 2
• 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 1, 2
• Weight management through physical activity and appropriate caloric intake to maintain BMI between 18.5-24.9 kg/m² and waist circumference <35 inches 1, 5
• Smoking cessation counseling and support should be provided to all women who smoke 1, 3

Treatment Goals and Monitoring

• Aim for LDL-C <100 mg/dL (or <70 mg/dL in very high-risk women) 1, 2
• Target HDL-C >50 mg/dL, triglycerides <150 mg/dL, and non-HDL-C <130 mg/dL 1, 2
• For diabetic patients, target HbA1c <7% if achievable without significant hypoglycemia 1, 2
• Blood pressure goal <130/80 mmHg for those with chronic kidney disease or diabetes; <140/90 mmHg for others 2

Additional Treatment Considerations

• Hormone therapy and selective estrogen-receptor modulators (SERMs) should not be used for prevention of cardiovascular disease 1, 2
• Consider screening for depression in women with coronary heart disease and refer/treat when indicated 2
• For refractory symptoms, additional options include:
  • Tricyclic medications such as imipramine (50 mg daily) which can reduce chest pain frequency by 50% 1
  • Transcutaneous electrical nerve stimulation or spinal cord stimulation for pain control 1
  • Enhanced external counterpulsation for symptom management 3

Prognosis and Follow-up

• Microvascular dysfunction is not benign, with a 2.5% annual risk of adverse cardiac events including myocardial infarction, stroke, heart failure, and death 3
• Women with no or minimal obstructive disease but documented myocardial ischemia have a 9.4% rate of death or MI over 4 years 1
• Regular follow-up is essential to monitor symptoms, adjust medications, and assess for disease progression 6

Pitfalls and Caveats

• Women are often falsely reassured despite the presence of ischemic heart disease because of a lack of obstructive CAD 6
• Microvascular dysfunction should be considered in women with typical anginal symptoms, evidence of myocardial ischemia, and normal coronary arteries 7
• Comprehensive risk factor reduction is essential even with minimal atherosclerotic disease on angiography 1
• Despite improvement in symptoms with weight loss and risk factor control, studies show this may not always translate to improved coronary microvascular function 5
• Large randomized outcome trials are still needed to optimize treatment strategies to improve morbidity and mortality 3, 4