Exploring coronary microvascular dysfunction from functional impairment and structural damage

Coronary microvascular dysfunction (CMD) is a syndrome characterized by myocardial ischemia resulting from structural and/or functional impairments of the coronary microvasculature, which includes pre-arterioles, arterioles, and capillaries. It has taken center stage in cardiovascular research due to its established role in triggering heart failure with preserved ejection fraction (HFpEF). The pathogenesis of CMD is closely associated with endothelial dysfunction, characterized by both structural and functional impairment of endothelial cells. This interplay between functional and structural injury underlies the significant heterogeneity in clinical phenotypes and hemodynamic characteristics across CMD subtypes, thus highlighting the necessity for a multidimensional investigation of its underlying pathological mechanisms. This review article systematically elaborates the pathophysiological features of CMD with a focus on two dimensions: microcirculatory functional regulation and vascular structural remodeling, aiming to provide a theoretical foundation for innovations in clinical diagnosis and treatment strategies.