Date of Award


Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Basmah Safdar


We hypothesized that patients in the Yale CMD registry with coronary microvascular dysfunction (CMD) would have worse cardiac outcomes and lower cognition at follow-up when compared with patients with normal hearts. At enrollment, participants were administered the Montreal Cognitive Assessment (MoCA) Participants were administered a symptom questionnaire, the telephone Montreal Cognitive Assessment (T-MoCA) and the oral trail-making test parts A & B (OTMTA & OTMTB). Chart review was conducted to determine long-term outcomes. Outcomes of interest included death, myocardial infarction (MI), reperfusion with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), stroke, transient ischemic attack (TIA), hospitalization for heart failure exacerbation, hospitalization for unstable angina, hospitalization and ED visits for cardiac reasons, and all hospitalization and ED visits. We found that participants with CMD had lower scores on MoCA compared with normal heart participants (median score 22 vs. 25, p < 0.05) and were less likely to pass (27% vs 75%, p < 0.05). The association was statistically significant even when adjusting for age, sex, Hispanic ethnicity, race, educational level, MI risk as measured by Thrombolytics in Myocardial Infarction (TIMI) score and Duke Activity Status Index (DASI) score. At follow-up, CMD participants had a lower T-MoCA score (17 vs. 18) and were less likely to pass (50% vs. 64%) but these results were not statistically significant. CMD participants when compared with normal heart or coronary artery disease (CAD) participants were more likely to experience a major adverse cardiac event (MACE), had greater all-cause mortality, were more likely to visit the ED, and were more likely to be hospitalized during the course of the follow-up period but these results were not statistically significant. Failing MoCA at enrollment was associated with a statistically significantly longer time to first MACE or other cardiac hospitalization (median 935 days vs 319 days, p < 0.05). Failing MoCA at enrollment had greater all-cause mortality, greater ED utilization, and greater rates of hospitalization throughout the study period but these associations were not shown to be statistically significant. We conclude that CMD is an independent risk factor for cognitive impairment. We are the first study to report this finding. Additionally, we conclude that cognitive impairment may be a predictor of poor cardiac outcomes in patients who present to the ED with chest pain and that close follow-up of patients with chest pain but without evidence of obstructive CAD is warranted.


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