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Increasing evidence suggests that CMD may contribute to myocardial \u2018Ischemia and No Obstructive Coronary Artery disease\u2019 (INOCA). In the present study, we tested the hypothesis that CMD results in perturbations in myocardial perfusion and oxygen delivery using a novel swine model with multiple comorbidities. DM (streptozotocin), HC (high-fat diet) and CKD (renal embolization) were induced in 10 female swine (DM\u2009+\u2009HC\u2009+\u2009CKD), while 12 healthy female swine on a normal diet served as controls (Normal). After 5\u00a0months, at a time when coronary atherosclerosis was still negligible, myocardial perfusion, metabolism, and function were studied at rest and during treadmill exercise. DM\u2009+\u2009HC\u2009+\u2009CKD animals showed hyperglycemia, hypercholesterolemia, and impaired kidney function. During exercise, DM\u2009+\u2009HC\u2009+\u2009CKD swine demonstrated perturbations in myocardial blood flow and oxygen delivery, necessitating a higher myocardial oxygen extraction\u2014achieved despite reduced capillary density\u2014resulting in lower coronary venous oxygen levels. Moreover, myocardial efficiency was lower, requiring higher oxygen consumption for a given level of myocardial work. These perturbations in myocardial oxygen balance were associated with lower myocardial lactate consumption, stroke volume, and LVdP\/d\n                    <jats:italic>t<\/jats:italic>\n                    <jats:sub>max<\/jats:sub>\n                    , suggestive of myocardial ischemia and dysfunction. Further analyses showed a reduction in adenosine-recruitable coronary flow reserve, but this was exclusively the result of an increase in basal coronary blood flow, while maximal coronary flow per gram of myocardium was maintained; the latter was consistent with the unchanged arteriolar wall\/lumen ratio, arteriolar density and peri-arteriolar collagen content. However, isolated small arteries displayed selective blunting of endothelium-dependent vasodilation in response to bradykinin in DM\u2009+\u2009HC\u2009+\u2009CKD swine, suggesting that changes in coronary microvascular function rather than in structure contributed to the perturbations in myocardial oxygen delivery. In conclusion, common comorbidities in swine result in CMD, in the absence of appreciable atherosclerosis, which is severe enough to produce perturbations in myocardial oxygen balance, particularly during exercise, resembling key features of INOCA.\n                  <\/jats:p>","DOI":"10.1007\/s00395-020-0778-2","type":"journal-article","created":{"date-parts":[[2020,7,7]],"date-time":"2020-07-07T07:03:34Z","timestamp":1594105414000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":53,"title":["Perturbations in myocardial perfusion and oxygen balance in swine with multiple risk factors: a novel model of ischemia and no obstructive coronary artery disease"],"prefix":"10.1007","volume":"115","author":[{"given":"Jens","family":"van de Wouw","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oana","family":"Sorop","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruben W. 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