Abstract
Coronary microvascular remodeling and ischemia in hypertension
An increasing amount of evidence suggests that the development of myocardial ischemia in hypertensive patients without angiographically demonstrable coronary artery disease, may at least in part be due to anatomic and functional abnormalities of the coronary microvasculature. Studies employing cardiac imaging techniques, in particular positron emission tomography (PET), have demonstrated that the coronary flow reserve (CFR), i.e. the ratio of myocardial blood flow (MBF) during near maximal vasodilatation (pharmacologically-induced) to resting MBF, is significantly impaired in hypertensive patients with or without left ventricular hypertrophy (LVH). In the absence of significant coronary stenoses, an abnormal CFR is suggestive of dysfunction of the coronary microcirculation. In parallel, mechanistic studies have suggested that microvascular dysfunction can be a result of several interacting mechanisms, including myocyte remodeling, vascular (intramyocardial coronary arteriole) remodeling, and decreased vasodilatory capacity of the coronary microcirculatory endothelium.
Furthermore, PET studies of patients with hypertrophic cardiomyopathy have demonstrated that the severity of CFR impairment is an independent predictor of clinical deterioration and death in these patients and may precede clinical deterioration by years. Similarly, preliminary studies in hypertensive patients with or without LVH have suggested that long-term therapy with the combination of the ACE inhibitor, perindopril 2 mg, and the diuretic, indapamide 0.625 mg, may improve the status of coronary microcirculation in these patients, although these findings need to be substantiated in larger studies.
Résumé
Il existe de plus en plus de données qui suggèrent que, chez les patients hypertendus exempts de maladie coronaire objectivée par angiographie, la survenue d’une ischémie myocardique pourrait être liée, au moins en partie, à des anomalies anatomiques et fonctionnelles de la microcirculation coronaire. Des études ayant fait appel aux techniques d’imagerie cardiaque, notamment à la tomographie par émission de positons (PET), ont démontré que la réserve coronaire (RC), c’est-à-dire le rapport du débit sanguin myocardique (DSM) lors d’une vasodilatation sous-maximale (induite pharmacologiquement) sur le DSM de repos, est altérée de manie`re significative chez les patients hypertendus, que ces derniers présentent ou non une hypertrophie ventriculaire gauche (HVG). En l’absence de sténose coronaire significative, une RC anormale témoigne d’une dysfonction de la microcirculation coronaire. Paralle`lement, des études mécanistes semblent indiquer que cette dysfonction microvasculaire pourrait résulter de plusieurs mécanismes intriqués, à savoir le remodelage myocytaire, le remodelage vasculaire (au niveau des artérioles coronaires intramyocardiques) et la diminution de la capacité de vasodilatation de l’endothélium des microvaisseaux coronaires.
De plus, des études par PET menées chez des patients atteints de cardiomyopathies hypertrophiques ont démontre que la sévérité de l’altération de la RC est un facteur prédictif indépendant d’aggravation clinique et de décès chez ces patients et peut précéder la dégradation clinique de plusieurs années. De même, des études préliminaires chez des patients hypertendus présentant ou non une HVG semblent indiquer que, chez de tels sujets, le traitement à long terme par l’association de perindopril (2 mg), un inhibiteur de l’enzyme de conversion (IEC), et d;indapamide (0,625 mg), un diurétique, peut améliorer la microcirculation coronaire, bien que ces données demandent à être confirmées par de plus vastes études.
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Camici, P.G. Remodelage microvasculaire et ischémie coronaire dans l’hypertension artérielle. Am J Cardiovasc Drugs 4 (Suppl 1), 25–30 (2004). https://doi.org/10.2165/00129784-200404991-00008
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DOI: https://doi.org/10.2165/00129784-200404991-00008