Variant angina induced by carbon monoxide poisoning: A CARE compliant case report

RATIONALE

Carbon monoxide (CO) poisoning can cause severe damage to the nervous system, and can also cause serious damage to organs, such as the heart, kidneys, and lungs. CO damage to myocardial cells has been previously reported. This can lead to serious complications, such as myocardial infarction.

PATIENT CONCERNS

A 47-year-old female patient complained of sudden chest pain for 30 minutes. Before admission, the patient had non-radiating burning chest pain after inhalation of soot.

DIAGNOSIS

An electrocardiogram showed that myocardial ischemia was progressively aggravated, manifested by progressive ST-segment elevation, and accompanied by T wave inversion and other changes. No obvious coronary stenosis was observed in a coronary angiographic examination. Therefore, the patient was considered to have developed variant angina resulting from CO poisoning-induced coronary artery spasm.

INTERVENTIONS

The patient was treated with drugs for improving blood circulation and preventing thrombosis, and underwent hyperbaric oxygen therapy.

OUTCOMES

Clinical symptoms relieved after the treatment.

LESSONS

Findings from this case suggest that CO can cause coronary artery spasm and it is one of the predisposing factors of variant angina. For these patients, hyperbaric oxygen therapy can improve blood circulation and prevent formation of thrombus and encephalopathy.

A woman with recurrent chest pain and ST-segment elevation

A 32-year-old female presents with recurrent episodes of unprovoked chest pain associated with inferior ST-segment elevation and reciprocal ST-segment depression. Coronary angiography during one of these episodes revealed coronary artery spasm that spontaneously resolved followed by resolution of these electrocardiographic changes. There was no atherosclerotic occlusive disease. Her cardiac markers were normal and echocardiogram showed no regional wall motion abnormalities. Electrocariogram and angiography findings are shown in Fig. 1.

Three cases of vasospastic angina that developed following the initiation of corticosteroid therapy

Three patients diagnosed as having remitting seronegative symmetrical synovitis with pitting edema syndrome, pemphigus erythematosus and idiopathic interstitial pneumonia were treated with oral prednisolone. Several weeks after starting the treatment, they experienced repeated chest pain attacks between midnight and early morning, although none of the patients had a past history of ischemic heart disease. One of the patients exhibited aggravation of symptoms soon after increasing the dose of prednisolone. A definitive diagnosis of vasospastic angina was made using electrocardiograms, coronary angiography and vasospasm provocation tests. These cases emphasize that clinicians should be aware of the possible occurrence of vasospastic angina following the initiation of corticosteroid therapy.

Clinical outcome of coronary stenting in patients with variant angina refractory to medical treatment: a consecutive single-center analysis

OBJECTIVE

To investigate the efficacy of coronary stenting in patients with variant angina refractory to medical treatment.

SUBJECTS AND METHODS

Variant angina was diagnosed in 81 patients admitted to the Department of Cardiology between January 2003 and June 2011. However, coronary stenting was performed in 21 patients refractory to medical treatment, but coronary angiography and intravascular ultrasound were performed in all patients, and acetylcholine provocative test was performed in 11 of the 21 patients refractory to medical treatment. Coronary angiography was repeated after 9-12 months in the 21 patients with coronary stents. Clinical follow-up time was 2.5 ± 3.1 years (range 1-8).

RESULTS

Of the 81 patients, coronary angiography and intravascular ultrasound did not reveal significant stenosis in 13 (16.0%), but revealed 20-75% fixed stenosis in the remaining 68 (84.0%) patients. The acetylcholine provocative test was positive in the 11 patients. Of the 21 patients with coronary stents, the spasm site was located in the right coronary artery in 16 (76.2%) and in the left anterior descending artery in the remaining 5 (23.8%) patients. During the 1- to 8-year follow-up period, 1 of the 21 patients with stents developed recurrent episodes of variant angina, 5 patients had occasional chest pain, and the other 15 were asymptomatic. Coronary angiography at 9-12 months after initial evaluation demonstrated no stenosis in 3 patients, 20-40% in-stent mild intimal hyperplasia in 15 patients, and 50-80% in-stent restenosis in 3 patients. Coronary stenting was performed again in 2 patients.

CONCLUSIONS

The present study showed that coronary stenting for severe refractory coronary vasospasm was effective and without serious complications. It can be an alternative and viable option for some patients who are refractory to medical therapy and at a high risk of acute coronary syndrome recurrence.

[Hyperventilation echocardiography in vasospastic angina pectoris diagnosing]

Hyperventilation echocardiography is an established diagnostic test in patients with suspected variant angina pectoris. It has got sufficient sensitivity (60-80%) and specificity (85-100%). Positive hyperventilation test is rarely found, which relates to low prevalence of variant angina. The diagnostic yield of the test depends on the population selected for testing: positive result can be expected in patients with a history of typical burning chest pain, ST segment elevation/depression and/or inversions of U wave during the chest pain episode, arrhythmias related to the chest pain, coronary artery stenosis less than 50% of artery diameter, multi-vessel disease, high activity of illness at the time of hyperventilation test. We present a case of 37 years old man with typical angina pectoris at rest and non-Q myocardial infarction, in whom the coronary angiography was negative. Variant angina pectoris was diagnosed by hyperventilation echocardiography. The ECG tracings showing typical ischemic patterns during the hyperventilation test are included.

[Variant angina: what to think in 2011?]

Spastic angina is considered rare but its prevalence is probably underestimated especially in case of atherosclerotic coronary lesions. Its diagnosis remains important due to its poor prognosis and therapeutic characteristics. We report three clinical cases illustrating two different clinical presentations and the problem of diagnosis of spastic angina. We performed a review of the literature essentially concerning commonly used diagnosis means and especially provocative testing for coronary spasm. This test needs to be adapted to the evolution of techniques and uses of coronary angiography in 2011, particularly the wide spread use of radial approach. Therefore new recommendations are needed, specifying the terms of provocative testing and establishing clear diagnosis criteria including clinical, electrocardiographic and angiographic data. Such guidelines would probably help to better diagnose and treat these patients in our practice.

Severe coronary artery spasm induced by epidural injection of bupivacaine hydrochloride: a case report

This report describes a case of variant angina induced by epidural infusion of bupivacaine hydrochloride for the treatment of intractable low back pain in a 66-year-old male patient with lumbar discopathy. Severe reversible coronary artery spasm of right coronary artery was demonstrated by coronary angiography. Withdrawal of epidural anesthesia and treatment with nitrates and calcium channel antagonists resulted in cessation of variant angina.

Recurrent variant angina pectoris due to Behçet's syndrome

We report a case of recurrent variant angina pectoris which occurred even while receiving antispastic treatment. Coronary angiography revealed no obvious lesion. Behçet's syndrome was diagnosed based on recurrent oral aphthous and genital ulcer as well as skin manifestation. After treatment with immunosuppressant, neither angina nor oral ulcer relapsed. We strongly believe that the variant angina is due to coronary vasospasm induced by Behçet's syndrome in this patient.

C-reactive protein in unstable angina pectoris and its relation to coronary angiographic severity and diffusion scores of coronary lesions

OBJECTIVE

We aimed to assess the relationship between C-reactive protein (CRP) and the severity and diffusion of coronary artery lesions in patients with unstable angina pectoris (UAP) and the independent association of CRP with this clinical situation.

METHODS

This cross-sectional, observational study included 50 patients. Classification by Braunwald was used for UAP. The severity and diffusion of angiographic coronary disease were graded according to Reardon's modified scoring system. Plasma CRP levels were quantified by immunoturbidimetry. Nonparametric tests were used for comparison of CRP and other risk factors, and logistic regression analysis for evaluation of independent association between CRP and unstable angina pectoris.

RESULTS

The severity score was 46±18 points in class IIB1 UAP, 36±20 points in class IIB2 and 53±18 points in class IIIB2 (p=0.017, class IIIB2 vs IIB2). Respectively, CRP levels were 6.6 mg/L, 3.8 mg/L and 4.8 mg/L (p=0.371, class IIB1 vs IIB2 vs IIIB2). Lesions with diffusion score 4 revealed higher CRP values than lesions with diffusion score 1 (11.1 mg/L vs 3.1 mg/L, p=0.048). Adjusting age, sex and smoking, assessment of partial correlation analysis showed a positive, moderately powerful and significant association between CRP levels and the severity and diffusion scores of the coronary lesions (r=0.30; p=0.034 and r=0.31; p=0.030, respectively) in the whole study group. Multiple logistic regression analysis showed no appreciable independent association between CRP and UAP (OR: 1.63, 95%CI: 0.90-5.63, p=0.093).

CONCLUSION

Although, CRP was correlated with the severity and diffusion of angiographic coronary disease in patients with UAP, there was no independent association between CRP and clinical severity of UAP.

A comparative study of eccentric and concentric coronary stenosis vasomotion in patients with Prinzmental's variant angina and patients with stable angina pectoris

BACKGROUND AND HYPOTHESIS

In patients with stable angina pectoris, eccentric stenoses have a greater potential for dynamic changes of caliber in response to vasoactive stimuli than concentric lesions. It is not known whether in patients with coronary artery spasm the degree of coronary vasoconstriction differs in eccentric versus concentric stenoses. Therefore, we examined the relationship between coronary stenosis morphology and the vasomotor response to vasoactive stimuli in patients with variant angina.

METHODS

Computerized quantitative angiography was used to measure minimum luminal diameter of eccentric and concentric stenoses before and after the administration of ergonovine and isosorbide dinitrate in 22 patients with Prinzmetal's variant angina and in 20 patients with chronic stable angina.

RESULTS

In patients with variant angina, mean stenosis diameter reduction with ergonovine was -0.85 +/- 0.38 and -1.12 +/- 0.69 mm in eccentric and concentric stenoses, respectively (p = NS). Isosorbide dinitrate promptly relieved spasm in all patients and increased the diameter of eccentric stenoses by 0.26 +/- 0.34 mm and that of concentric stenoses by 0.24 +/- 0.32 mm (p = NS). In patients with chronic stable angina, mean diameter reduction with ergonovine was -0.23 +/- 0.12 and -0.12 +/- 0.10 mm for eccentric and concentric stenoses, respectively (p < 0.05). Isosorbide dinitrate increased coronary diameter by 10% from baseline in 70% of eccentric and 38% of concentric stenoses (p < 0.01).

CONCLUSION

In patients with variant angina pectoris, eccentric and concentric spastic stenoses react similarly in response to vasoactive stimuli. In patients with chronic stable angina, eccentric stenoses are more likely to show vasomotor responses than concentric stenoses.

A case of congenital bilateral coronary-to-right ventricle fistula coexisting with variant angina

A coronary arteriovenous (AV) fistula consists of a communication between a coronary artery and a cardiac chamber, a great artery or the vena cava. It is the most common anomaly that can affect coronary perfusion. Yet bilateral involvement of a coronary fistula, constitutes an uncommon subgroup of coronary AV fistulas. We herein report on a case of bilateral coronary AV fistula that was coexistent with variant angina originating from the distal right ventricular branch of the right coronary artery and the distal septal branch of the left anterior descending artery, and the latter drained into the right ventricle.

A case of suspected vasospastic angina related to S-1 administration

A 58-year-old male with advanced gastric cancer underwent a total gastrectomy after neoadjuvant chemotherapy with paclitaxel and cisplatin. The combination chemotherapy was resumed postoperatively as adjuvant chemotherapy. Although no recurrence was observed after 6 months of adjuvant chemotherapy,the patient elected to receive further adjuvant chemotherapy with an oral drug. On the night of November 9,2006, he began taking S-1 at a dose of 50 mg twice daily. Fifty minutes after taking the first 50 mg of S-1,he experienced a squeezing chest pain at rest that was later accompanied by diaphoresis and nausea. The pain continued for approximately one hour,but had subsided by the time he reached an emergency room. Coronary angiography revealed a 50% eccentric stenosis in the proximal site of the right coronary artery,but there was no coronary lesion which could caused myocardial ischemia. Cardiac scintigraphy using 123I-BMIPP (123I-labeled beta-methyl-p-iodophenyl-pentadecanoic acid) showed a decreased uptake of BMIPP within the posterior wall,which improved one month later,so transient myocardial ischemia was confirmed. Since vasospastic angina related to S-1 administration was highly suspected,re-administration of S-1 was not performed. The patient is not currently receiving chemotherapy and remains under surveillance for relapse.

[Prinzmetal's angina: clinical manifestation in a 79-year-old man with atherosclerotic coronary artery disease]

A case of a 79-year-old man with risk factors of ischaemic heart disease is presented. He was admitted to the Cardiology Ward because of recurrent angina pectoris with ST-segment elevation in the anterior electrocardiographic leads. Coronary arteriography revealed 90% stenosis of the marginal branch of the left coronary artery, which was supplied by coronary angioplasty. During hospitalisation recurrent episodes of angina pectoris were noted, only in night hours, with ST-segment elevations in anterior electrocardiographic leads. Pharmacotherapy with calcium blockers and nitrates eliminated the episodes of chest pain in a ten-month follow-up.

Endothelial function and coronary spastic angina

Coronary spasm plays an important role in the pathogenesis of not only variant angina but also coronary heart disease in general including acute coronary syndromes, especially in the Japanese population. The vascular endothelium has been reported to be a multifunctional organ whose integrity is essential for normal vascular physiology. Vascular endothelial dysfunction can be a critical factor in the pathogenesis of ischemic heart disease. Acetylcholine and methacholine cause vasodilation by endothelium-derived relaxing factor when the endothelium is functioning normally, whereas they cause vasoconstriction when the endothelium is removed or damaged. Coronary spasm can be induced by a variety of stimuli with different mechanisms of action, including acetylcholine and methacholine. Patients with coronary spasm may have a disturbance in endothelial function as well as local hyperreactivity of the coronary arteries.

Diagnosis of multivessel coronary vasospasm by detecting postischemic regional left ventricular delayed relaxation on echocardiography using color kinesis

BACKGROUND

It is not known whether multivessel coronary spasm occurs spontaneously in patients who have variant angina (VA) with demonstrated multivessel spasm induced by intracoronary injection of acetylcholine (ACh). Regional left ventricular (LV) diastolic dysfunction or wall motion abnormality may persist after an episode of coronary vasospasm. Color kinesis (CK) is a recent development that facilitates the echocardiographic evaluation of regional diastolic wall motion.

METHODS AND RESULTS

Regional diastolic wall motion was evaluated using CK in 26 patients with VA within 1 week of the last episode of angina. The LV segmental filling fraction in the short-axis view during the first 30% of the diastolic filling time, expressed as a percentage, was used to objectively identify postischemic diastolic endocardial motion asynchrony. Diastolic asynchrony or regional LV delayed relaxation was noted in all 26 (100%) patients and in 14 (54%) it was detected in multiple vascular territories, suggesting multivessel spasm. Multivessel spasm was induced by ACh in 11 (79%) of the patients with suspected multivessel spasm by CK. In 11 (92%) of the 12 patients with multivessel spasm induced by ACh multiple regions of delayed relaxation had been noted by CK. The regions of delayed relaxation were largely consistent with the territories perfused by the arteries reacting to ACh (sensitivity: 96%, specificity: 91%).

CONCLUSION

ACh induced spasm in the same coronary arteries as those perfusing the regions with delayed diastolic wall motion detected by CK in most of the patients with VA, suggesting that multivessel spasm does occur spontaneously in patients with susceptible arteries.

Limitations of medical therapy in patients with pure coronary spastic angina

OBJECTIVES

To assess the efficacy of medication for the treatment of pure coronary spastic angina, 71 consecutive patients with this diagnosis who had undergone coronary arteriography in a hospital with a follow-up of at least 2 years were studied.

METHODS AND RESULTS

All 71 patients without significant organic stenosis were treated with long-acting calcium antagonists. The disappearance of chest pain attacks while receiving medical therapy was observed in 27 patients (38%), whereas the remaining 44 patients (62%) had chest pain attacks. Of special interest, 30 patients had more than one attack per month irrespective of the administration of calcium antagonists or isosorbide dinitrate. Medical treatment showed a good response in female patients (63% vs 31%, respectively; p < 0.05) and those with ST-segment elevation during selective spasm provocation tests (63% vs 30%, respectively; p < 0.05). In contrast, patients with a longer history of chest pain attacks before hospital admission and those with diffuse spasms (77% vs 34%, respectively; p < 0.01) had poor responses to medical treatment. In this study, neither sudden death nor acute myocardial infarction was observed during the follow-up periods.

CONCLUSION

The limitations of medical therapy, including the administration of long-acting calcium antagonists, were observed in 30 of 71 patients (42%) with pure coronary spastic angina. Medical treatment was effective in only 38% of patients with pure coronary spastic angina in Japan.