[Angiographic results of "atypical" chest pain]

BACKGROUND AND AIMS

Coronary angiography permits evaluation of coronary artery morphology and coronary pathology. It represents an accurate method of defining stenotic coronary lesions. Chest pain may be caused by coronary artery disease as well as by other cardiac and noncardiac disorders. However, sensitivity of clinical evaluation and noninvasive diagnostic assessment in detection of coronary artery disease is limited. Noninvasive diagnostic strategies give inconsistent results in about 10-30%. Here coronary angiography is regarded as an accurate method for appropriate diagnosis. Ist sophisticated apparatus, cost, and invasiveness necessitate well-considered application of this procedure. Therefore, it appears important to analyze coronary angiograms in patients with the referral diagnosis of "atypical" chest pain with inconsistent noninvasive testing or impossibility to perform noninvasive assessment.

PATIENTS AND METHODS

We analyzed records of 1,000 consecutive patients (625 men, 375 women, mean age 63.1 years), who underwent coronary angiography at our institution from January 5, 1998 to May 5, 1998.

RESULTS

49 patients (17 women, 32 men; mean age 59 years) were referred due to "atypical" chest pain. 21 (42.9%, nine women, twelve men) of these 49 patients had normal coronary arteries at angiography. 21 (42.9%) patients showed coronary artery disease with a diameter stenosis > 50%. In seven (14.2%) patients, coronary sclerosis with a diameter stenosis < 50% could be observed. Only five (29.4%) of the 17 women but 16 of the 32 men (50%) had coronary artery disease with a diameter stenosis > 50% (p < 0.01).

CONCLUSIONS

In unselected patients referred for coronary angiography due to "atypical" chest pain and inconsistent noninvasive testing or impossibility to perform noninvasive assessment. 42.9% had coronary artery disease with a diameter stenosis > 50%. Angiographic evaluation of symptomatic patients with "atypical" signs and symptoms and inconsistent noninvasive testing seems to be appropriate.

Cardiac arrest related to coronary spasm in patients with variant angina: a three-case study

We present three patients with variant angina pectoris and episodes of cardiac arrest. All of them had typical clinical symptoms, ST-segment changes in electrocardiogram, and coronary artery spasm confirmed by arteriography. They were treated with high doses of calcium antagonists and nitrates. An automatic cardioverter-defibrillator was implanted in the patient who developed ventricular fibrillation despite therapy with calcium antagonists. In another patient a DDD pacemaker was implanted because of high-degree atrioventricular block.

Diagnosis of vasospastic angina by hyperventilation and cold-pressor stress echocardiography: comparison to I-MIBG myocardial scintigraphy

OBJECTIVES

We assessed the usefulness of hyperventilation and cold-pressor stress echocardiography in the diagnosis of vasospastic angina compared with that of iodine-123 metaiodobenzylguanidine (123I-MIBG) myocardial scintigraphy.

BACKGROUND

Various noninvasive methods have been used to detect vasospastic angina, but they are not very sensitive in the diagnosis of vasospastic angina. 123I-MIBG images and stress echocardiography have recently been proposed as a useful tool for detecting vasospastic angina.

METHOD

Thirty patients (21 males and 9 females, mean age: 52 +/- 14 years) who complained of rest angina were enrolled for this study. The hyperventilation and cold-pressor stress echocardiography test consisted of hyperventilation for 6 minutes, followed by cold water pressor for 2 minutes under continuous electrocardiographic and echocardiographic monitoring. Left ventricular regional wall motion by echocardiogram was analyzed by using the 16-segment model, and wall motion ranging from normokinesis to dyskinesis was evaluated visually in each segment. Single-photon emission computed tomography images of 123I-MIBG myocardial scintigraphy were divided into 26 segments. Defect scores were established using the 4 grades. The echocardiographic criteria for coronary spasm was worsening wall motion and the scintigraphic criteria was defect score more than moderately reduced. Acetylcholine was selectively injected into the right coronary artery (20 microg and 50 microg) and left coronary artery (20 microg, 50 microg, and 100 microg).

RESULTS

Of 30 patients, 20 patients had coronary spasm on coronary angiography with an intracoronary injection of acetylcholine, whereas 10 patients showed no spasm. Multivessel spasms were observed in 15 patients. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of hyperventilation and cold-pressor stress echocardiography for diagnosing in patients with vasospastic angina were 90%, 90%, 95%, 82%, and 90%, respectively. However, those of 123I-MIBG myocardial scintigraphy for diagnosing in patients with vasospastic angina were 90%, 40%, 75%, 67%, and 73%, respectively. The specificity of hyperventilation and cold-pressor stress echocardiography was significantly higher than that of 123I-MIBG myocardial scintigraphy (P <.05).

CONCLUSION

The specificity of hyperventilation and cold-pressor stress echocardiography in diagnosing coronary spasm were higher than that shown by 201I-MIBG myocardial scintigraphy.

[Rest delayed images on 99mTc-MIBI myocardial SPECT as a noninvasive screen for the diagnosis of vasospastic angina pectoris]

Diagnostic usefulness of 99mTc-MIBI myocardial SPECT at rest was examined in 39 cases of coronary vasospastic angina pectoris who were diagnosed by a positive reaction to ergonovine provocation. SPECT was performed 45 minutes (early image) and 3 hours (delayed image) after the intravenous injection of approximately 600 MBq of MIBI. Decrease in accumulation was ranked by four defect scores (0: normal; 1: slight decrease; 2: moderate decrease; 3: severe decrease) and the total defect score was evaluated semiquantitatively. The washout rate between the normal area and the spasm area was also evaluated quantitatively using bull's eye. As a result, 15 cases (15/39; 38.4%) showed decreased accumulation in the early image and 27 cases (27/39; 69.2%) showed decreased accumulation in the delayed image. All of the cases which showed decreased accumulation in the early image had decreased accumulation in the delayed image as well. In 6 cases (6/34; 17.6%) showed ST wave changes during exercise ECG and 16 cases (16/34: 47%) showed decreased accumulation in the exercise myocardial SPECT. The washout rate of MIBI in the decreased accumulation area was significantly higher than that of the normal area. Of 32 ergonovine induced vasospastic area, 23 areas (72%) exhibited decreased accumulation in the delayed image for the same area. Decreased accumulation in the delayed image in MIBI was due to the enhanced washout, which, in turn, indicated declined retention of MIBI by mitochondrial membrane. In coronary vasospastic angina pectoris, spasm induced ischemia was thought to have an effect on the mitochondria. This study suggested that even with a normal exercise ECG and exercise myocardial SPECT, there's a strong possibility of coronary vasospastic angina pectoris if a decreased accumulation was found in the delayed image in the MIBI myocardial SPECT at rest. Hence, in diagnosing coronary vasospastic angina pectoris, the delayed image in the MIBI myocardial SPECT at rest was believed to be useful.

Circulating T-lymphocyte activation in patients with variant angina

BACKGROUND

Both experimental and pathological studies suggest that immune response and inflammation may play an important role in the pathogenesis of coronary spasm.

DESIGN

To elucidate the role of systemic immune and inflammatory responses in the pathogenesis of coronary spasm, we studied circulating T-lymphocyte activation in variant angina patients (VAPs), stable effort angina patients (EAPs) and in control participants.

METHODS

Twenty documented VAPs, 13 EAPs and 20 control participants were studied. To evaluate T-lymphocyte activation, T-lymphocyte surface antigen expression, including CD3, CD4, CD8 and HLA-DR, was measured by two-colour flow cytometric analysis. Serum-soluble interleukin-2 receptor (sIL-2R) and C-reactive protein (CRP) were also measured by enzyme-linked immunosorbent assay. We restudied 10 of the VAPs to investigate the relationship between the disease activity of variant angina and T-lymphocyte activation.

RESULTS

The percentage of CD3+/DR+ T-lymphocytes in VAPs (14.8%) was significantly higher than in EAPs (10.7%, P < 0.05) and control participants (9.7%, P < 0.005); however, levels of sIL-2R were the same among the three groups. Levels of CRP were within normal range in all VAPs. The percentage of CD8+/DR+ T-lymphocytes was significantly higher in VAPs (9.5%, P < 0.005) than in EAPs (5.5%) and control participants (5.9%), whereas the percentage of CD4+/DR+ T-lymphocytes was similar among the three groups. The percentage of activated T-lymphocytes in VAPs was unchanged during the follow-up period (mean intervals, 10 months).

CONCLUSIONS

These results indicate that the chronic activation of T-lymphocytes, especially CD8+ T-lymphocytes, may be involved in the pathogenesis of coronary spasm.

Coronary microvascular spasm causes myocardial ischemia in patients with vasospastic angina

OBJECTIVES

We aimed to test the hypothesis that coronary microvascular spasm (MVS) alone causes myocardial ischemia in patients with angina attributable to epicardial coronary spasm, and to determine whether there is a difference in clinical characteristics between those with and without microvascular spasm.

BACKGROUND

Patients with "vasospastic angina" have epicardial coronary artery spasm, but it is unknown whether coronary microvessel disease also contributes to the occurrence of angina in these patients.

METHODS

We studied 55 consecutive patients with angina in whom epicardial coronary spasm was provoked by intracoronary acetylcholine (ACH).

RESULTS

In 14 patients (25.5%, Group 1), submaximal dose of ACH induced myocardial ischemia (chest pain, ischemic electrocardiogram changes, lactate production) without large epicardial spasm, suggesting the occurrence of coronary microvascular spasm. By contrast, the remaining 41 patients (Group 2) had evidence of myocardial ischemia only when epicardial spasm was angiographically demonstrated. The Group 1 patients were predominantly women (p < 0.05) and had a history of prolonged (>30 min) chest pain (p < 0.05), whereas the Group 2 patients were more likely men and smokers (p < 0.01).

CONCLUSIONS

Myocardial ischemia most probably due to coronary MVS was demonstrated in a sizable portion of patients with epicardial vasospasm, preferentially in women having both typical and prolonged anginal pain. The result suggests that coronary microvascular disease may also contribute to angina in patients with "vasospastic angina."

Impaired endothelium-dependent vasodilation in the brachial artery in variant angina pectoris and the effect of intravenous administration of vitamin C

Endothelial dysfunction in the coronary artery contributes to the pathogenesis of variant angina, and endothelial dysfunction in variant angina may be associated with increased oxidant stress in the systemic arteries. We investigated whether endothelial dysfunction exists in the peripheral artery in patients with variant angina, and also examined the effect of vitamin C, an antioxidant, on endothelium-dependent vasodilation. Using high-resolution ultrasound, both the flow-mediated vasodilation (FMD, endothelium-dependent vasodilation) and sublingual nitroglycerin-induced vasodilation (NTG-D, endothelium-independent vasodilation) in the brachial artery were measured in 28 patients with variant angina and 24 control subjects who had normal coronary arteries. FMD was significantly impaired in patients with variant angina compared with control subjects (1.8 +/- 2.2% vs 6.4 +/- 4.9%, p <0.001). FMD and NTG-D before and after intravenous administration of either vitamin C or placebo were measured in 17 patients with variant angina. FMD significantly improved after the administration of vitamin C (from 2.2 +/- 2.4% to 4.5 +/- 1.6%, p <0.01), but not after administration of the placebo (from 2.0 +/- 2.6% to 1.7 +/- 1.9%). The improved FMD due to vitamin C in patients with variant angina, however, was not significantly different from that in the control subjects. NTG-D was not significantly different between patients with variant angina and control subjects (14.0 +/- 7.8% vs 13.6 +/- 5.0%) and it was also not affected by vitamin C.

IN CONCLUSION

(1) FMD in the brachial artery is impaired in patients with variant angina, and (2) the acute administration of the antioxidant, vitamin C, was observed to reverse this endothelial dysfunction. These findings support the theory that the systemic inactivation of nitric oxide due to oxidative stress might exist in patients with variant angina.

The effect of left ventricular diastolic dysfunction on the pathogenesis of angina decubitus

OBJECTIVE

To investigate the effect of left ventricular diastolic dysfunction on the pathogenesis of angina decubitus (AD).

METHODS

The study population consisted of three groups: 20 individuals without cardiovascular studied as group I. Group II included 20 patents with coronary artery disease and without AD. Thirty-one patients with AD and ejection fraction (EF) > 50% were studied as group III. Group II and III were matched for age, EF and extent of coronary artery disease.

RESULTS

Left ventriculography (LVG) showed that left ventricular (LV) first 1/3 filling fraction (1/3FF) was significantly lower in group III than in group II and I (both P < 0.001), but LV late 1/3 FF was much higher in group III than in group II and I (P < 0.05, P < 0.01). Left ventricular end-diastolic pressure (LVEDP) was markedly increased before and after LVG in group II and III as compared with group I (both P < 0.05, both P < 0.001). The difference of LVEDP caused by left atrial contraction (left atrial contraction pressure difference, LACPD) before and after LVG was much higher in group III than in group I ( P < 0.01, P < 0.001). However, there we significant differences in LVEDP and in LACPD between before and after LVG only in group III (both P < 0.01).

CONCLUSION

The patients with AD have LV diastolic dysfunction, which may be closely related to the pathogenesis of angina decubitus.

Successful treatment of vasospastic angina with a coronary stent

Calcium antagonists are the treatment of choice in vasospasm angina when no stenosis or mild stenosis are present. We present a case in which ergonovine echocardiography showed vasospasm of the right coronary artery despite optimal medical treatment. Stenting of a mild stenosis in that artery successfully controlled vasospasm and a pre-discharge ergonovine echocardiographic test was negative. The patient remains asymptomatic one year after stenting.

Intravascular ultrasound findings of negative arterial remodeling at sites of focal coronary spasm in patients with vasospastic angina

BACKGROUND

There are few data about the intravascular ultrasound (IVUS) findings in patients with vasospastic angina, especially regarding patterns of vascular remodeling.

METHODS AND RESULTS

Coronary spasm was documented by angiography and electrocardiographic evidence of ischemia in 36 patients after administration of ergonovine (cumulative doses up to 350 microg). After relief of spasm with 1000 microg of intracoronary nitroglycerin, quantitative angiography and IVUS imaging were performed and analyzed by standard methods. The 36 focal spasm sites were compared with the proximal and distal reference segments. The angiographic baseline minimum lumen diameter measured 1.78 +/- 0.66 mm, which decreased to 0.66 +/- 0.38 mm with ergonovine provocation (P <.0001), increased to 2.66 +/- 0.64 mm after intracoronary nitroglycerin (P <.0001 compared with baseline and after ergonovine), and did not change after IVUS imaging (2.66 +/- 0.63, P =.9). By IVUS, atherosclerotic lesions were observed at all coronary spasm sites; the mean plaque burden measured 56% at the spasm site and 35% at the reference. Spasm site plaque composition was hypoechoic in 31 and hyperechoic, noncalcific in 5; there was no calcium. The mean eccentricity index (maximum divided by minimum plaque thickness) was 6.7. Positive remodeling (spasm site arterial area greater than proximal reference) was present in 5; intermediate remodeling (proximal reference greater than spasm site greater than distal reference arterial area) was present in 7; and negative remodeling (spasm site arterial area less than distal reference) was present in 24.

CONCLUSIONS

Sites of vasospasm in patients with variant angina showed characteristics of early atherosclerosis, except for an unusually high incidence of negative arterial remodeling.

Systemic endothelial function is preserved in men with both active and inactive variant angina pectoris

To test the hypothesis that coronary spasm could be a coronary manifestation of systemic endothelial dysfunction and that the activity of coronary spasm could influence systemic endothelial function, we examined brachial flow-mediated, endothelium-dependent vasodilation and nitroglycerin-induced endothelium-independent vasodilation with high-resolution ultrasound in 11 men with variant angina pectoris (6 active and 5 inactive) without established coronary atherosclerosis. Endothelium-dependent vasodilation in peripheral circulation was preserved in men with active and inactive variant angina pectoris, suggesting that systemic endothelial dysfunction is not involved in either the pathogenesis or the activity of coronary spasm.

Mental stress test is an effective inducer of vasospastic angina pectoris: comparison with cold pressor, hyperventilation and master two-step exercise test

BACKGROUND

Cold pressor, hyperventilation and exercise stress tests were usually used for inducing an angina attack in patients with vasospastic angina pectoris. We induced vasospastic angina attack using the mental calculation stress test, and compared the results with those using other stress tests.

SUBJECTS AND METHODS

Subjects were 29 patients with vasospastic angina pectoris. Their ages were 60.8+/-8.4 years. Coronary vasospasm was induced by an acetylcholine infusion test during coronary angiography. The mental stress test was performed as follows; after memorizing six digits numbers, they repeated these numbers in reverse for 5 min, and performed serial subtraction of 17 from 1000 for 5 min. Blood pressure, heart rate and ECG were recorded every 1-5 min during the mental stress test. The serum concentrations of epinephrine and norepinephrine were measured before and during the mental stress test. We compared these results with those obtained using cold pressor, hyperventilation and the Master two-step exercise stress test.

RESULTS

(1) Eight of the 29 patients (28%) showed ischemic ST-T change, which was caused by the mental stress test. (2) The increase in norepinephrine was greater in patients with an ST-T change than without an ST-T change (0.11+/-0.06 vs. 0.04+/-0.04 ng/ml, P<0.01). (3) The incidence of the ST-T change caused by the mental stress test (28%) was similar to the cold pressor test (27%) and greater than that caused by the hyperventilation test (13%). The incidence of ST-T change caused by the Master two-step test was 55%.

CONCLUSIONS

The mental stress test is an effective inducer of vasospastic angina attack, and attack may be induced by neurohumoral vasoconstrictive reflex and/or increased left ventricular afterload.

Coronary artery stent placement in patients with variant angina refractory to medical treatment

We performed a prospective study to establish the efficacy of coronary stent placement in a highly selected group of patients with focal coronary artery spasm in whom anginal attacks could not be prevented by full medical therapy. The results of this study indicate that intracoronary stent placement may represent an alternative and feasible treatment for patients with vasospastic angina refractory to aggressive medical therapy.

Variant angina is not associated with angiotensin I converting enzyme gene polymorphism but rather with smoking

BACKGROUND

Angiotensin converting enzyme (ACE) perhaps plays roles in regulating coronary vasomotor tone by producing angiotensin II and degrading bradykinin.

OBJECTIVES

We sought to investigate the role of ACE gene polymorphism in the pathogenesis of variant angina and to compare it with that of other clinical risk factors for male patients with variant angina and age-matched and sex-matched control subjects.

METHODS

We studied 78 male patients with variant angina who exhibited spontaneous or provoked coronary spasms during coronary angiography and compared prevalences of ACE gene genotype (deletion D and insertion I) and other risk factors between this group of patients with variant angina and age-matched and sex-matched control subjects whose angiograms were normal and in whom the ergonovine test did not cause spasms (n = 80).

RESULTS

Smokers were more prevalent in the group of patients with variant angina (P < 0.05). Genotype and allele prevalences of the group of patients with variant angina (0.14, 0.53 and 0.33 for DD, DI and II and 0.41 and 0.59 for D and I, respectively) were no different from those of the control group (0.16, 0.49 and 0.35 for DD, DI and II and 0.40 and 0.60 for D and I). Multiple logistic regression analysis showed that smoking was a significant risk factor for variant angina (odds ratio 2.61, 95% confidence interval 1.03-6.66) whereas ACE genotype was not.

CONCLUSIONS

Variant angina is associated with an environmental factor, such as smoking, rather than a genetic factor, such as ACE gene polymorphism.

Abnormal fatty acid metabolism in patients with coronary vasospasm

Although various noninvasive methods have been used to detect vasospasm, none of them are sensitive enough for patients with sporadic attacks. Since abnormal fatty acid metabolism is observed in ischemic myocardium, 123I-beta-methyl-p-iodophenyl pentadecanoic acid (BMIPP), a radiolabeled fatty acid analog, has recently been proposed as a useful tracer for detecting myocardial damage. The aim of this study was to clarify the clinical implications of decreased myocardial BMIPP uptake in patients with vasospastic angina. We evaluated 53 patients with vasospastic angina (32 with clinically documented vasospasm [Group-A] and 21 with vasospasm induced by ergonovine provocation [Group-B]) and 27 control subjects, 20 in Group-A were re-evaluated 6 months after medical treatment. The territorial regions of vasospasm-induced coronary artery, the wall motion by left ventriculography, and BMIPP uptake were compared. Vasospasm was induced in multiple coronary arteries in 29 (55%) patients. Reduced wall motion and decreased BMIPP uptake were observed in 19 (36%) patients and 47 (89%) patients, respectively. The sensitivity and specificity of determination of vasospasm-induced coronary arteries with BMIPP scintigraphy were 71% (69/97 coronary arteries) and 88% (126/143), respectively. Vasospasm was re-induced by ergonovine provocation in 8 patients (Group-I) and not re-induced in 12 (Group-II) after treatment. In Group-I, improvement of decreased BMIPP uptake was lower than in Group-II (19+/-11 vs. 59+/-22%, mean+/-SD, p < 0.001). The regions in which vasospasm was re-provoked exhibited decreased BMIPP uptake. Abnormal fatty acid metabolism was more often observed than wall motion abnormality in the vasospastic region in patients with vasospastic angina. BMIPP scintigraphy is a highly accurate and non-invasive technique for determining the presence and location of vasospasm.

Phase changes caused by hyperventilation stress in spastic angina pectoris analyzed by first-pass radionuclide ventriculography

To understand the effect of hyperventilation (HV) stress in patients with spastic angina, left ventricular (LV) contraction was analyzed by quantitative phase analysis. The study was performed on 36 patients with spastic angina pectoris, including vasospastic angina pectoris (VspAP: 16 patients) and variant angina pectoris (VAP: 20 patients). First-pass radionuclide ventriculography (first-pass RNV) was performed at rest and after HV stress, and standard deviation of the LV phase distribution (SD) was analyzed. The SD was lower in patients with VspAP than in VAP (12.8+/-1.4 degrees vs. 14.6+/-2.2 degrees, p < 0.005) at rest. After HV stress, the SD (HVSD) tended to increase in VspAP patients (62.5%), whereas the SD decreased in VAP patients (70%). Due to HV stress, the percentage change in SD (%SD) in VspAP patients was 8.9+/-23.7% whereas that in VAP patients was -9.1+/-17.3% (p < 0.01). Moreover, phase histograms were divided into HVSD increase and HVSD decrease groups. The HVSD increase group had a decrease of HVEF, but the HVSD decrease group tended to have more decreased HVEF than the HVSD increase group. These results indicate that spastic angina pectoris patients show various responses to HV stress. The HVSD increase group might have additional myocardial ischemia due to regional coronary spasm. In contrast, in the HVSD decrease group severe LV dysfunction or diffuse wall motion abnormality might have been generated, and this caused a reduction in the SD value. Phase analysis would therefore add new information regarding electrocardiographically silent myocardial ischemia due to coronary spasm, and HV stress might increase sensitivity for the detection of abnormalities in quantitative phase analysis, especially in VspAP patients.

Coronary NIR stent implantation for refractory variant angina

A 44-year-old woman with severe variant angina refractory to maximal medical therapy and at risk of sudden death was successfully treated by a NIR stent implantation on a moderate lesion of LAD. Six months later she was asymptomatic, without in-stent restenosis. This procedure represents an alternative treatment for patients with refractory vasospastic angina.

Collateral flow detected by a Doppler guide wire in a case of vasospastic angina

We could detect recruitable backward collateral flow in systole and diastole by using a Doppler guide wire during coronary artery spasm in a 42-year-old female among 20 patients with documented variant angina. The electrocardiogram (ECG) showed no ST-segment deviation, although she had chest pain and her coronary angiography showed a totally occluded right coronary artery. After administration of isosorbide dinitrate (ISDN) the collateral flow disappeared and the flow pattern recovered to normal. The good collateral flow pattern in patient with totally occluded coronary artery due to spasm was indicated to relieve myocardial ischemia, even when the patient felt chest pain.