[61 years old woman with atypical angina and high global risk]

Bei einer 61-jährigen Frau mit blander Vorgeschichte entwickelt sich eine Dyspnoesymptomatik, die von einer labilen Hypertonie begleitet ist. Die kardiologische Abklärung ergibt bei Hyperventilationsneigung ein pathologisches Belastungs-EKG, jedoch eine überdurchschnittlich gute ergometrische Leistungsfähigkeit. Die Befundkonstellation spricht gegen eine koronare Problematik, sodass auf eine zusätzliche funktionelle oder invasive Abklärung verzichtet wird. Angesichts des auf 19% erhöhten, intermediären Globalrisikos wird zum Ausschluss einer koronaren Herzkrankheit eine CT-Koronarangiographie durchgeführt. Diese ergibt überraschend eine ca. 50%ige weiche Plaque im proximalen RIVA. Die hsCRP ist erhöht, was eine potentielle Plaque-Vulnerabilität anzeigen könnte. Trotz einem Calcium-Score von 0 wird die Patientin als hohes Risiko eingestuft und mit Aspirin und einem hoch dosierten Statin behandelt. Für dieses Vorgehen besteht bisher keine Evidenz. Auf Grund des Calcium-Score allein wäre nach geltender Empfehlung das intermediäre Risiko auf ein niedriges zurückgestuft worden [4].

Current clinical features, diagnostic assessment and prognostic determinants of patients with variant angina

BACKGROUND

Clinical characteristics and outcome of patients with variant angina were assessed in the 1970-1980s of the past Century. The recent progress in prevention, diagnosis and treatment of coronary artery disease may have significantly modified clinical characteristics and prognosis of these patients.

METHODS

From January 1991 to December 2002, 202 patients (57.1+/-12 years; 166 men) were diagnosed to have variant angina at our Institute. Detailed clinical findings and clinical events were prospectively collected for each patient.

RESULTS

The median time from the first angina attack to diagnosis was 2 months (range 1-276), with diagnosis requiring >6 months in 31.7% of patients. Coronary angiography (n=183) showed normal coronary arteries in 42.1% of patients and significant coronary stenoses (>50%) in 44.3%, with multi-vessel disease in 8.7%. Diagnosis of variant angina was done during coronary angiography in 3% of cases during the first half of the study period, but in 42% of patients in the second half of the study period. Major cardiac events (MCE, i.e., death, resuscitation from cardiac arrest, myocardial infarction) occurred in 41 patients (20.3%), with 43.9% of events occurring within 1 month of symptom onset. The only variable significantly associated with MCE was the detection during angina of ST segment elevation in both anterior and inferior ECG leads (odds ratio 3.24; 95% confidence interval 1.43-7.36; P=0.005).

CONCLUSION

Our data suggest that variant angina is still a frequently overlooked diagnosis, and a timely diagnosis would be crucial to prevent early life-threatening events. Patients with diffuse ST segment elevation on ECG are those at the highest risk of MCE, independently of angiographic findings.

Single coronary artery with prepulmonic coursing left main coronary artery manifesting as prinzmetal's angina

We report the case of a 32-year-old man who presented at the emergency department with severe chest pressure, left arm pain, and dizziness. These symptoms were described as intermittent, occurring after exercise and at rest. He had undergone several stress tests during the past 8 years, but no objective evidence of ischemia was produced. His history of hyperlipidemia and increasing frequency of symptoms prompted us to perform coronary angiography, which showed a single coronary artery with an ostium at the right sinus of Valsalva. The vessel had an initial, mixed common trunk that gave rise to both the right coronary artery proper and to the left coronary artery. The left main trunk followed a prepulmonic course. The anatomic features were eventually confirmed by computed tomographic angiography. The left main stem had a fixed 50% to 60% area narrowing, at baseline study. A treadmill stress myocardial perfusion study showed no evidence of ischemia. The patient was referred to a 2nd facility, where intravascular ultrasonography, at baseline, revealed 63% left main narrowing without evidence of atherosclerosis. Acetylcholine provocation demonstrated worsening of the stenosis to about 80%, with reproduction of angina and ST-segment depression, which indicated that medical management of spasm might provide symptomatic relief.

Polymorphic ventricular tachycardia induced by coronary vasospasm: a malignant case of variant angina

Variant angina is generally a benign disease with self limiting symptoms. But in some cases serious ventricular arrhythmias which can lead to death can be seen. In this paper we present a case of variant angina who subsequently developed polymorphic ventricular tachycardia and was treated successfully with long acting nitrate and calcium channel blockade therapy.

[Vasospastic angina]

Vasospastic angina is associated with ventricular arrhythmias, acute myocardial infarction and sudden arrhythmic death. The main ischemic mechanism in vasospastic angina is coronary spasm. Because the demonstration of spontaneous coronary spasm is difficult, a number of methods which can provoke spasm in susceptible patients were imagined. The most used clinical methods of diagnostic provocation testing were analyzed.

Klotho gene polymorphism may be a genetic risk factor for atherosclerotic coronary artery disease but not for vasospastic angina in Japanese

BACKGROUND

The klotho gene, originally identified by insertional mutagenesis in mice, suppresses multiple aging phenotypes, including atherosclerosis. We tested the hypothesis that the G-395A polymorphism of the klotho gene is associated with increased risk for 2 types of ischemic heart disease in Japanese.

METHODS

The study population consisted of 197 patients with coronary heart disease (CAD) who had >75% luminal diameter narrowing, 77 patients with vasospastic angina (VSA) without significant fixed coronary artery disease, and 331 healthy control subjects.

RESULTS

The frequency of the A allele carriers of the klotho gene was significantly higher in the CAD group than in the control group (29.9% vs. 19.0%). The unadjusted odds ratio for CAD in the A allele carriers compared with the control group was 1.82 (p=0.004) and a traditional risk-adjusted logistic regression model revealed that the A allele was an independent predictor of CAD (odds ratio, 1.76; p=0.03). In contrast, the frequency of the A allele carriers was not significantly different in the VSA group (23.4%; adjusted odds ratio, 1.18.

CONCLUSIONS

The -395A polymorphism of the human klotho gene may be a genetic risk factor for IHD and not for VSA.

[Syncope as a first manifestation of Prinzmetal's angina in a 49-year-old woman. A case report]

A case of a 49-year-old woman with episodes of syncopes as a first manifestation of variant angina is presented. She was admitted to cardiology ward because of recurrent angina associated with marked ST segment elevation in the inferior and anterior electrocardiographic leads. Previously she was diagnosed at a neurological ward because of nocturnal syncopes without accompanying chest pain but with associated hypotonia and bradycardia of about 36 beats/min. Coronary arteriography revealed non-significant coronary stenosis of two vessels (left and right coronary artery) and coronary spasm close to these obstructions. Therapy with calcium channel blockers as well as giving up smoking eliminated the episodes of chest pain and syncope in a twelve-month follow-up.

Variations in presentation and various options in management of variant angina

Patients with variant angina represent a diagnostic and therapeutic dilemma. Variant angina is a disease with various causes, variations in treatment guidelines and variable prognosis. In an era of robotic cardiac surgery and automatic cardioverter defibrillators, it is regrettable that we lack enough information on the optimal management of this entity. Lack of randomised trials and a tendency for spontaneous remissions makes interpretation of results difficult. We review the pathophysiology, presentation and recent developments in medical and surgical management of variant angina. Literature is full of conflicting data and it is difficult to make specific recommendations.

Variant angina associated with bitter orange in a dietary supplement

The Food and Drug Administration has banned the sale of ephedrine-based weight-loss products because of their association with many cardiovascular adverse effects. Bitter orange is now being used as a stimulant in "ephedra-free" weight-loss supplements but was recently implicated in adverse cardiovascular sequelae. To our knowledge, this report describes the first case of variant angina associated with bitter orange in a dietary supplement.

Need for documentation of guidelines for coronary artery spasm: an investigation by questionnaire in Japan

BACKGROUND

Because there are no guidelines concerning coronary spasm in Japan, the present study examined the current status of the spasm provocation test.

METHODS AND RESULTS

Questionnaires concerning the number of cases of coronary angiography, percutaneous coronary intervention, and invasive/non-invasive spasm provocation tests over 3 years (2001-2003) and the status of spasm provocation tests were sent to members of the Japanese Circulation Society in 120 cardiology hospitals in the Chugoku and Shikoku areas. Completed surveys were returned from 45 hospitals, giving a collection rate of 38%. As a spasm provocation agent, acetylcholine tests were performed in 29 hospitals, and ergonovine tests in 18 hospitals. Non-invasive spasm provocation tests were performed in only 9 hospitals (20%). In total, 5,267 patients underwent acetylcholine spasm provocation test (2,387 patients) or ergonovine spasm provocation test (2,880 patients) and vasospastic angina was diagnosed in 1,663 (2.4%) patients. Invasive spasm provocation tests were performed in 7.8% of patients with diagnostic catheterization and the spasm-positive rate was 31.6%. The difference among hospitals concerning the number of invasive spasm provocation tests was remarkable, and the angiographic spasm-positive standard and acetylcholine/ergonovine dose varied among the hospitals.

CONCLUSIONS

Guidelines on coronary spasm in Japan are essential to overcome the current differences between institutions.

[Clinical features of patients with atypical coronary artery spasm]

OBJECTIVE

This study is aimed to compare the clinical characteristics of patients with typical and atypical coronary artery spasm.

METHODS

Out of 64 patients with chest pain at rest and without significant coronary artery stenosis, coronary artery spasm was provoked by intracoronary injection of acetylcholine in 46 patients, including 12 with ST segment elevation (typical coronary artery spasm group) and 34 without ST segment elevation (atypical coronary artery spasm group). The demographic data, coronary angiographic findings, treadmill electrocardiogram, dipyridamole and rest thallium-201 myocardial perfusion computed tomography, and the follow-up clinical data of the two groups were compared.

RESULTS

The patients with typical coronary artery spasm were younger (47 +/- 6 vs. 58 +/- 12, P < 0.05) than patients with atypical coronary artery spasm group. Hyperlipidemia were more common in atypical coronary artery spasm group (74% vs. 33%, P < 0.05) and myocardial bridging was more common in patients with typical coronary artery spasm group (67% vs. 32%, P < 0.01). Focal coronary spasm during acetylcholine provocation was seen in 92% patients with typical coronary spasm and in 32% patients with a atypical coronary artery spasm (P < 0.01) while diffuse coronary spasm was seen in 8% patients with typical coronary spasm and in 68% patients with a atypical coronary artery spasm (P < 0.01). All patients with coronary artery spasm were treated with aspirin, calcium channel blockers, long-acting nitroglycerine, with or without lipid-lowering drugs, 2 patients with typical coronary spasm and 4 patients with atypical coronary spasm were rehospitalized due to chest pain and rest of the patients remained free of chest pain during the median follow-up period of 18 +/- 14 months.

CONCLUSION

Atypical coronary artery spasm is common in patients with rest angina and diffuse coronary microvascular spasm might be the cause of chest pain in these patients.

Relation of high-sensitivity C-reactive protein level with coronary vasospastic angina pectoris in patients without hemodynamically significant coronary artery disease

We prospectively investigated the relation of high-sensitivity C-reactive protein (hs-CRP) to coronary vasospasm and no hemodynamically significant coronary artery disease (CAD) in a sample of 428 patients who underwent coronary angiography. These patients were assigned to 1 of 3 groups. The control group consisted of 66 patients who had no coronary vasospasm and no hemodynamically significant CAD. The vasospasm group consisted of 116 patients who had coronary vasospasm and no hemodynamically significant CAD. The acute coronary syndrome (ACS) group consisted of 246 patients who had ACS and hemodynamically significant CAD. Serum hs-CRP was measured immediately before coronary angiography. Patients were followed for subsequent cardiac events and mortality. Median hs-CRP levels in the control, vasospasm, and ACS groups were 1.0, 5.5, and 8.2 mg/L, respectively. The proportion of hs-CRP increased from the lowest to the highest tertile in the control, vasospasm, and ACS groups, respectively. In the control and vasospasm groups, multivariate analysis showed that hs-CRP was independently associated with a diagnosis of coronary vasospastic angina pectoris (odds ratio 68.74, 95% confidence interval 8.03 to 588.71, p<0.001). During a median follow-up period of 26 months (range 0.4 to 48), 27 cardiac deaths occurred in the ACS group, whereas no cardiac death occurred in the control and vasospasm groups. In conclusion, serum hs-CRP level measured immediately before coronary angiography was an independent marker of coronary vasospasm in patients who had no hemodynamically significant CAD.

Comparison of plasma serotonin levels in patients with variant angina pectoris versus healed myocardial infarction

Patients with variant angina pectoris showed greater serotonin plasma levels than did control subjects and patients with healed myocardial infarction. The levels also tended to be greater in those with >1 episode/month than in those with fewer episodes. Moreover, patients with variant angina pectoris also had greater levels of nitrite and nitrate plasma levels than did control subjects or patients with healed myocardial infarction, partly, perhaps, as a compensatory mechanism.

Unusual case of single coronary artery: questions of methods and basic concepts

Coronary artery anomalies continue to constitute a confusing subject in modern cardiology. While most anomalies are considered to have a benign prognosis, the literature and cardiologic culture frequently imply an intrinsic, systematic association of coronary anomalies with severe clinical presentations. We present a case of unusual single coronary artery, in order to elucidate the logical process that should be used to study similar cases. A 56-year-old female presented with a 6-year history of atypical chest pain and an abnormal electrocardiogram. Heart catheterization revealed an abnormal coronary tree interpreted by some observers as a benign coronary anomaly, by others to indicate the need for coronary angioplasty. A nuclear stress test was performed after 1 year of unrelenting symptoms and showed mildly abnormal findings, leading to a more definitive angiographic study that clarified the anatomy and the prognosis. The case is essentially and only an example of single coronary artery with origin of all branches from the right coronary sinus, but with an unusual triple origin of the branches serving the left anterior descending territory. The notion that a case of single coronary artery may have significant prognostic and clinical repercussion is frequently repeated in the current inconclusive literature. A rational discussion should deal both with individual case objective evidence and theoretical general consideration.

[Variant angina mimicking right ventricular infarction--a case report]

A case of a 59-year-old man with recurrent angina associated with ST-segment elevation in leads II, III, aVF and V4R-V6R, cardiogenic shock and complete atrio-ventricular block, is presented. Coronary angiography was normal. Therapy with calcium channel blockers was effective. Difficulties in the treatment of patients with variant angina are discussed.

Variant angina in a 17-year-old male

Chest pain is a common complaint in adolescents. It is mostly from musculoskeletal origin. Variant angina is a rare cause of chest pain in adolescents. Here we report a 17-year-old male with severe chest pain accompanied by transient ST-segment elevation in leads II, III, avF of the electrocardiogram showing/revealing variant angina associated with acute myocardial ischaemia. Data obtained from laboratory tests, including serial cardiac markers, were normal and subsequent cardiac catheterization revealed a normal coronary anatomy. The patient has been asymptomatic since discharge, and treatment with calcium channel antagonists with nitrate seems to assure a good prognosis.

[Variant angina pectoris associated with Morgagni-Adams-Stokes syndrome--case report]

We report a case of Prinzmetal angina initially manifested with short losses of consciousness in a 55-year-old man hospitalized in the Department of Coronary Artery Disease, Institute of Cardiology, Jagiellonian University Medical College in Cracow. Clinical symptomatology of the presented case, causes and mechanism of loss of consciousness in variant angina as well as treatment methods are discussed.

Changing Characteristics of Patients with Vasospastic Angina in the Era of New Calcium Channel Blockers

In the 1980s, clinical characteristics and long-term prognosis of patients with vasospastic angina (VSA) were investigated; however, they remain to be updated after the introduction of new calcium channel blockers, benidipine and amlodipine, in 1990s. Our patient cohort registered 726 patients with VSA from January 1980 to December 2002. Before and after 1990, 138 and 527 patients were respectively entered in this study with a follow-up rate of 92%. Most of the patients were treated with calcium channel blockers, while benidipine and amlodipine were used in 28% and 21% of them only after 1990. Survival without cardiovascular events (96% versus 96%) at 5 years remained good before and after 1990. The presence of significant coronary stenosis had a negative prognostic impact both before and after 1990, whereas after 1990, diabetes mellitus, smoking, and a history of myocardial infarction became more influential. Among the calcium channel blockers, benidipine showed a better prognosis. These results suggest that in the era of new calcium channel blockers, the prognosis of patients with VSA remains good with more prognostic impact of diabetes mellitus, smoking, and a history of myocardial infarction and that benidipine might have some better prognostic effects.