Michael Gratch

🫀⚠️ We fix the arteries.
 But what if the problem isn’t just in the lumen of the main coronary arteries? This Lancet study goes straight at a blind spot we all know exists—but rarely quantify. 🧠 The setup 1003 real-world patients undergoing invasive angiography + full physiology (FFR, CFR, IMR) So not theory. 👉 actual coronary physiology in practice 🔍 The uncomfortable finding 👉 Coronary microvascular dysfunction (CMD) in ~16% of patients And not just in “normal coronaries”: - 21.5% WITH obstructive CAD - 9.3% WITHOUT obstructive CAD Translation 👉 Microvascular disease is NOT a niche problem 👉 It is embedded within “classic CAD” 📉 Outcomes (this is where it gets real) At ~2 years: 👉 18.8% events with CMD 👉 10.5% without 👉 HR ~1.9 And here’s the kicker: In patients WITHOUT obstructive CAD: 👉 HR ~3.45 🧠 Translation (again, because this matters) You can have: 👉 “normal” coronaries (by FFR) 👉 no revascularization And still: 👉 a 3x higher risk ⚠️ The paradigm problem Our entire workflow is built around: 👉 stenosis 👉 FFR 👉 revascularization But this paper shows: 👉 fixing epicardial disease does NOT normalize risk 🧬 Why? Because CMD reflects: - microvascular dysfunction - endothelial dysfunction - inflammation - diffuse myocardial injury Not a plumbing problem 👉 a biological one 🧠 My take This paper doesn’t just add information. It exposes a structural limitation: 👉 we are solving the visible part of the disease And missing: 👉 the microcirculation 👉 the diffuse component 👉 the residual risk That is the underlying atherosclerotic/metabolic/inflammatory milieu. ⚡ The real implication If you only measure: 👉 stenosis 👉 FFR You are ignoring: 👉 a major determinant of outcomes 🚨 Bottom line CAD ≠ epicardial stenosis Ischemia ≠ FFR alone 👉 Coronary disease is multi-level 👉 And the microcirculation is not optional Final uncomfortable thought We’ve optimized PCI. We’ve optimized stents. We’ve optimized FFR. But: 👉 we still don’t systematically measure what happens beyond them #Cardiology #CMD #Microcirculation #FFR #CardiacRisk #PrecisionMedicine