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성균관대학교 의과대학, 삼성서울병원

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Lancet, May 21 2026, S0140-6736(26)00666-5 | https://doi.org/10.1016/S0140-6736(26)00666-5 Coronary microvascular dysfunction and cardiovascular outcomes (Multicenter FLOW-CMD Registry): a prospective, multicentre cohort study in South Korea

Assoc Prof Joo Myung Lee MD ^a†, Seung Hun Lee MD ^b,c†, Dong Hyun Gim MD^a, Sang Yoon Lee MD ^a, Ki Hong Choi MD ^a, Joon Ho Ahn MD^b, Prof Young Joon Hong MD^b, Prof Hyun Kuk Kim MD ^d, Kwan Yong Lee MD ^e, Eun Ho Choo MD ^e, Ki-Hyun Jeon MD ^f, Hangyul Kim MD ^g, Min Gyu Kang MD ^g, Prof Jin-Sin Koh MD ^g, Hyun Sung Joh MD ^h, Taek Kyu Park MD ^a, Prof Jeong Hoon Yang MD ^a, Prof Young Bin Song MD^a, Prof Seung-Hyuk Choi MD^a, Prof Hyeon-Cheol Gwon MD ^a, Prof Joo-Yong Hahn MD ^a for the Multicenter FLOW-CMD investigators‡

^aDivision of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
^bChonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
^cDuke University Medical Center, Durham, NC, USA
^dChosun University Hospital, University of Chosun College of Medicine, Gwangju, South Korea
^eSeoul St Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
^fSeoul National University Bundang Hospital, Seongnam, South Korea
^gGyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, South Korea
^hSeoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea

Correspondence to: Assoc Prof Joo Myung Lee
^†Joint first authors

Abstract

Background: Coronary microvascular dysfunction often coexists with epicardial coronary artery disease. Data regarding its prevalence and prognosis in patients undergoing invasive coronary angiography are scarce. This study aimed to evaluate the prevalence and prognosis of coronary microvascular dysfunction in patients undergoing clinically indicated invasive coronary angiography in routine practice.

Methods: In this prospective, multicentre cohort study done in seven tertiary medical hospitals in South Korea, consecutive patients aged 18 years and older who were referred for clinically indicated invasive coronary angiography were systematically screened and evaluated by coronary physiological assessment. Obstructive epicardial coronary artery disease was defined as an intermediate stenosis (40-90% diameter stenosis), with fractional flow reserve of 0·80 or less or severe stenosis (>90% of diameter stenosis) treated with revascularisation without fractional flow reserve measurement. Coronary microvascular dysfunction was identified as coronary flow reserve below 2·0 and index of microcirculatory resistance of ≥25. The primary endpoint was a composite of all-cause death, myocardial infarction, clinically driven repeat revascularisation, or hospitalisation for heart failure. The Multicenter FLOW-CMD Registry study is registered with ClinicalTrials.gov (NCT05369182).

Findings: Between April 22, 2022, and Nov 19, 2024, 5764 patients were screened and 1003 patients were enrolled (756 men and 247 women). Among these patients, coronary microvascular dysfunction was observed in 123 (21·5%) of 573 patients with obstructive epicardial coronary artery disease and in 40 (9·3%) of 430 patients without obstructive epicardial coronary artery disease. At a median follow-up of 1·9 years, the primary endpoint occurred in 26 patients (2-year Kaplan-Meier estimate 18·8%) with coronary microvascular dysfunction and 70 patients (2-year Kaplan-Meier estimate 10·5%) with preserved microvascular function (hazard ratio 1·91 [95% CI 1·22-2·99]; p=0·0047).

Interpretation: In patients with suspected ischaemic heart disease undergoing invasive coronary angiography, coronary microvascular dysfunction coexisted with epicardial coronary artery disease and was associated with a higher risk of the composite of all-cause death, myocardial infarction, clinically driven repeat revascularisation, or hospitalisation for heart failure.

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