THE CORONARY CIRCULATION IN CARDIAC-HYPERTROPHY

Left ventricular hypertrophy is a common and important risk factor for cardiac mortality and morbidity. Cardiac hypertrophy adversely affects coronary perfusion because hypertension, its most frequent cause, is a major risk factor for coronary disease, and because cardiac hypertrophy may be associated with myocardial ischemia even in the absence of atheromatous coronary disease due to disturbances in coronary physiology. Several studies have demonstrated impairment of coronary reserve in human and experimental cardiac hypertrophy. Normal autoregulation of coronary flow may be disturbed in cardiac hypertrophy for many reasons, including (a) increased perfusion pressure in hypertension, (b) increased diastolic and systolic left ventricular pressures, in addition to disturbed coronary physiology. Studies undertaken in the presence of maximal coronary vasodilatation indicate an increased minimal coronary vascular resistance in hypertrophied hearts. Because such measurements were determined in the presence of maximal coronary vasodilation, they are likely to indicate a reduced arteriolar lumenal cross-sectional area per unit mass of tissue. Studies of cardiac and coronary morphology support an imbalance in myocardial and coronary growth in cardiac hypertrophy, but further evidence is needed to confirm this. Myocardial contraction impairs coronary flow, and available evidence suggests that this systolic impairment may be greater in hypertrophied myocardium, and that this may be an additional factor in limiting coronary flow in hypertrophy. A further important feature of impaired coronary reserve in cardiac hypertrophy is its distribution. Studies using radiolabeled microspheres indicate that coronary reserve is reduced in endocardial regions to a much greater extent than epicardial regions. Previously, treatment of conditions such as hypertension, which are commonly associated with hypertrophy, have concentrated on correction of the main defect. It is important to bear in mind, however, that such treatments may have direct and indirect effects on the coronary circulation, which may have an important bearing on preserving myocardial function. An important aspect of future research will be to determine the effects of treatment on coronary perfusion.