Does prevalence of migraine and Raynaud's phenomenon also increase in Korean patients with proven variant angina?

BACKGROUND

The incidence of coronary artery spasm in oriental patients is higher than that in western patients. Oriental patients with variant angina (VA) frequently show normal or insignificant coronary artery stenosis by angiogram, compared with western patients. The prevalence of migraine and Raynaud's phenomenon in oriental patients with VA has not yet reported.

OBJECTIVE

We did a prospective study on the prevalence of migraine and Raynaud's phenomenon in patients with proven VA compared with those in two control groups using a radioisotope technique following ice water exposure. Simultaneously, we studied lipid profiles of each group.

METHODS AND RESULTS

migraine was diagnosed if the score in part A totalled 7 or more of 26, and Raynaud's phenomenon was diagnosed if the score in part B totalled 4 or more of 11 by Miller et al. Technetium-99m-labeled red blood cells (99mTc-RBC) radionuclide angiography was performed in all patients. Patients were included in a prospective protocol. Patients were grouped as follows: Group I: 20 patients with proven VA; Group II: 30 patients with coronary artery disease; Group III: 31 patients without heart disease. Age and sex of patients were not statistically different among the three groups. Migraine was diagnosed in 8 patients (40.0%) of group I and in 6 patients (20.0%) of group II and in 12 patients (38.7%) of group III. Raynaud's phenomenon was reported in 2 (10.0%) of the patients in group I and in 5 (16.1%) of the patients of group III. The mean index ratio of the digital blood flow of right over left hand on static image was 0.85 +/- 0.07 (mean +/- S.E.M.) of the patients of group I, 0.73 +/- 0.03 of the patients of group II and 0.74 +/- 0.04 of the patients of group III. The mean flow index ratio of right over left hand of the digital blood flow on dynamic study was 0.51 of the patients of group I, 0.43 of the patients of group II and 0.43 of the patients of group III. The score of migraine did not differ significantly among the three groups. The score of Raynaud's phenomenon of patients with variant angina did not differ significantly from that of patients in the non-coronary control group, although it differed significantly from that of patients in the coronary control group. But, the prevalence of migraine and Raynaud's phenomenon (questionnaire and radionuclide angiography) in patients of group I did not differ significantly from that in groups II and III. In the end, more patients with variant angina than coronary or non-coronary control group did not reach the predetermined point level for the diagnosis of migraine and Raynaud's phenomenon. Lipid profiles were not significantly different among three groups.

CONCLUSIONS

This result suggests that variant angina may not be a manifestation of a generalized vasospastic disorder in Korean patients.

Resting asynchronous left ventricular contraction abnormality analyzed by a phase method in spastic angina pectoris

Quantitative phase analysis of equilibrium ventriculography was performed to study the character of left ventricular (LV) wall motion abnormalities in patients with spastic angina pectoris, who may have clinically and electrocardiographically silent ischemia combined with myocardial stunning, during rest and hyperventilation stress testing.

METHODS

Phase analysis of the left ventricle at rest was performed by equilibrium radionuclide ventriculography in 13 control subjects and 36 patients with spastic angina pectoris. First-pass methodology along with hyperventilation stress testing was performed to assess spasm occurrences. Phase analysis of equilibrium multigated blood-pool scintigrams was performed to evaluate LV asynchrony at rest.

RESULTS

The mean s.d. of LV phase distribution in the patients with variant and vasospastic angina was greater than that in the healthy control subjects (11.28 +/- 1.79 and 10.02 +/- 1.57 degrees versus 6.16 +/- 1.07 degrees). In addition, the mean s.d. of LV phase distribution in the variant angina group was greater than that in the vasospastic angina group. Furthermore, a linear correlation was found between the s.d. of LV phase distribution at rest and the percent decrease in ejection fraction during hyperventilation stress.

CONCLUSION

Asynchronous LV contraction without significant hypokinesis was detected at rest in spastic angina pectoris. The severity of this asynchronous contraction corresponded well with decreases in ejection fraction during hyperventilation stress testing. Thus, analysis of the s.d. of LV phase distribution at rest is expected to provide useful information regarding LV asynchrony in spastic angina pectoris.

Is cardiac migraine a clinical entity?

Chest pain because of a disorder of the coronary circulation is assumed to be ischemic in nature. Irrespective of the underlying pathophysiological mechanism, it is accepted that all routes lead to myocardial ischemia in the pathway to anginal pain. The authors describe a patient with a history of vasoactive disorders including migraine, asthma, documented variant angina with prolonged episodes of chest pain, and scintigraphic evidence of inferior and posterior wall ischemia during exercise and ergonovine testing in the absence of significant underlying stenoses. Remarkably, severe retrosternal chest pain, ST segment depression in multiple leads, and relative increased uptake in the inferior and posterior walls on Tc-99m sestamibi tomographic images developed during pharmacologic coronary vasodilatation with dipyridamole, leading the authors to speculate as to the possible existence of a nonischemic chest pain syndrome caused by coronary vasodilatation either in association with variant angina or as a separate entity.

Long-term follow-up of coronary narrowing with spasm

In order to clarify the fate of coronary narrowing with spasm, repeat angiograms of coronary narrowing with and without spasm were compared. The mean interval between the first and second angiograms was 3.6 years (range, 1.1-8.5 years). Improvement of narrowing was more frequent in the vasospastic group (23%) than in the group without spasm (3%, P < 0.005). The cause of this improvement in the vasospastic group may have been the resolution of the spasm in the first angiogram, but the presence of intravascular thrombus or bleeding or edema of the coronary arterial wall may have resolved in the second angiogram.

Values of intravenous ergonovine test with two-dimensional echocardiography for diagnosis of coronary artery spasm

The purpose of this study was to evaluate the clinical validity of the bedside ergonovine test with digital echocardiography and the side-by-side continuous cineloop display method (ergonovine echocardiography) as a noninvasive diagnostic tool for coronary artery spasm. Bedside ergonovine test was performed in 66 patients who showed coronary vasospasm during coronary angiography including provocation testing (group with variant angina) and 39 patients with normal angiograms and no evidence of coronary artery spasm (group with nonanginal pain). A bolus of ergonovine maleate (0.025 or 0.05 mg) was injected at 5-minute intervals up to total cumulative dosage of 0.35 mg, and 12-lead electrocardiography and two-dimensional echocardiography were recorded every 3 minutes after each injection. Left ventricular wall motion was analyzed with a commercially available quad system. The positive criteria of bedside ergonovine test included reversible ST segment elevation or depression on electrocardiograms (ECG criteria) and reversible regional wall motion abnormalities by echocardiography (Echo criteria). The overall sensitivity and specificity of ECG criteria were 53% (35/66; 95% confidence interval 41% to 65%) and 100%, respectively. By Echo criteria the sensitivity increased to 89% (59/66; 95% confidence interval 81% to 97%), with a specificity of 95% (37/39).(ABSTRACT TRUNCATED AT 250 WORDS)

Crow-Fukase syndrome: a case associated with vasospastic angina

The patient is a 60-year-old man who developed numbness of the extremities, paralysis, hyperpigmentation of the skin, hypertrichosis, anasarca and chest pain at the age of 58 years. The diagnosis of Crow-Fukase syndrome was made and myeloma was not found. Prednisolone therapy was effective but chest pain reappeared every morning when prednisolone was tapered to 30 mg alternate day. Coronary arteriogram showed no stenosis but administration of acetylcholine into the coronary artery produced ST elevation in electrocardiogram, chest pain and coronary artery stenosis which were relieved by administration of nitrates into the coronary artery.

Clinical and angiographic characteristics of patients with multivessel coronary spasm in variant angina. Significance of progressive course of angina and disease activity

The purpose of this study was to investigate the incidence of multivessel coronary spasm and compare the clinical characteristics between patients with and without multivessel coronary spasm. In variant angina, it is controversial whether coronary hyperreactivity to vasoconstrictor stimuli is localized to a segmental lesion in only one coronary artery. Moreover, the clinical characteristics of patients with multivessel coronary spasm have never been investigated. Sixty-three patients (51 men and 12 women; mean age, 56 years; range 35-72 years) with variant angina and documented ST-segment elevation during a spontaneous attack underwent spasm provocation testing with selective intracoronary injection of ergonovine. All but 4 patients who experienced spontaneous attacks during cardiac catheterization had induced coronary spasm associated with ST-segment elevation and chest pain. Multivessel coronary spasm was found in 27 (43%) of 63 patients. By univariate analysis, a high frequency of angina (> or = 3 times/week), occurrence of a spontaneous attack within 24 hours after withdrawal of medication, a long history of angina and a progressive course of angina were significantly associated with multivessel coronary spasm. Multivariate analysis indicated a positive correlation between multivessel coronary spasm and progressive angina. Multivessel coronary spasm was found in 43% of patients with variant angina. Patients with multivessel coronary spasm have some unique clinical features. These results may increase the understanding of the pathophysiology and natural course of variant angina.

Assessment of quantitative exercise thallium-201 emission computed tomography in patients with vasospastic angina--value of washout rate analysis

This study was performed to assess the value of washout rate analysis of quantitative exercise thallium-201 emission computed tomography in vasospastic angina patients without significant coronary stenosis. Quantitative analysis of both thallium-201 perfusion and washout rate before and after drug treatment was performed in 48 patients with vasospastic angina and no significant coronary artery stenosis. All of the patients attained more than 90% of their age-predicted heart rate during each exercise test. Before drug treatment, 26 patients exhibited exercise-induced ischemia (perfusion defects on stress polar map), 17 did not exhibit exercise-induced ischemia (normal stress and washout rate polar maps), and the remaining 5 patients showed no perfusion defects, but did show extensive abnormal washout rates. On coronary angiography, multivessel coronary spasm was documented in 12 of the 26 patients with exercise-induced ischemia, in 7 of the 17 patients without exercise-induced ischemia and in 4 patients with an extensive abnormal washout rate and a normal stress polar map. In the 17 patients without exercise-induced ischemia, the mean washout rate was significantly decreased (p < 0.05) in association with a significant decrease in the double product (p < 0.05) after drug treatment. Of the 26 patients with exercise-induced ischemia, 18 (group 1) showed an increase in the mean washout rate with improved perfusion defect after drug treatment. The remaining 8 patients (group 2) showed a decrease in the mean washout rate with improved perfusion defect after drug treatment, which increased significantly on repeat exercise test performed after additional increased doses of antianginal drugs were administered (p < 0.01). The number of patients with multivessel coronary spasm was significantly high in group 2 (p < 0.01). Thirteen patients showed an extensive abnormal washout rate before drug treatment, including 8 patients with exercise-induced ischemia and 5 patients with no perfusion defects, who showed an increased mean washout rate after drug treatment (p < 0.05). These findings indicate that washout rate analysis aids in the diagnosis in vasospastic angina patients with exercise-induced ischemia. Some patients with exercise-induced ischemia can not be detected by thallium-201 perfusion analysis alone, especially those with multivessel coronary spasm and when this procedure is performed after drug treatment. In addition, a high frequency of abnormal washout rate in vasospastic angina may result not only from exercise-induced ischemia due to main epicardial coronary artery spasm, but also from microspasm, or impairment of microcirculation or myocyte.

Comparison of the distribution of myocardial blood flow between exercise-induced and hyperventilation-induced attacks of coronary spasm: a study with thallium-201 myocardial scintigraphy

Exercise and hyperventilation tests are often used as the provocative tests for coronary artery spasm. To examine the distribution of myocardial blood flow during exercise-induced and hyperventilation-induced attacks of coronary spasm, thallium-201 myocardial scintigraphy was performed in 47 patients with variant angina. The extent and severity scores and severity index (severity score/extent score) of scintigraphic perfusion defect were calculated. In 32 patients, anginal attack associated with ST elevation on the electrocardiogram was induced by exercise; in 23 patients, the attack was induced by hyperventilation. In patients with either anterior or inferior wall ischemia, both the extent and severity scores and severity index in the scintigram were significantly greater in exercise-induced anginal attack than those in hyperventilation-induced attack. In patients with simultaneous anterior and inferior wall ischemia, they tended to be greater in exercise-induced attack. In eight patients in whom anginal attack was induced by both exercise and hyperventilation, these scores and index were significantly greater in exercise-induced attack than those in hyperventilation-induced attack. These data suggest that myocardial ischemia during exercise-induced attack is enhanced as compared with that during hyperventilation-induced attack. Thallium-201 scintigraphy combined with exercise testing seems to be more sensitive for detecting myocardial ischemia induced by coronary spasm.

[Prinzmetal's variant angina: a case report]

Prinzmetal's angina is a variant of the classic exertion dependent angina pectoris. Typical is the appearance of the symptoms at rest during early morning hours. It is due to spasms in the coronary arteries. Various provocation tests may be used to trigger spasms, among others hyperventilation which leads to vasoconstriction of coronary arteries. The case of a 53-year-old patient with Prinzmetal's angina is described in whom spasms of the right coronary artery could be evoked by hyperventilation. The following pathogenetic mechanisms may be possible in Prinzmetal's angina: disturbed endothelial permeability, endothelial dysfunction, or secretion of vasoconstrictive substances as well as local hypersensitivity of segments disturbed by atherosclerotic lesions to circulating vasoconstrictors.

Influence of exercise-induced coronary artery spasm on thallium-201 initial distribution and washout kinetics in patients with variant and classic angina pectoris

Thallium-201 single-photon emission computed tomography was performed immediately, and 2 and 4 hours after exercise-induced anginal attack in 2 groups of patients with either exercise-induced coronary spasm or severe fixed stenosis on the isolated proximal left anterior descending coronary artery. All patients with variant angina had transient ST-segment elevation during the exercise-induced attack for thallium-201 scintigraphic study. Both perfusion defects and 4-hour washout abnormalities were significantly greater in patients with variant angina than in those with stable effort angina (p < 0.01). In patients with stable effort angina, thallium-201 activity in ischemic regions (as a percentage of initial count in the normal region) progressively decreased, whereas in patients with variant angina it increased from 38% (initial) to 48% (2 hours), and then declined to 42% (4 hours). The initial normalized thallium-201 activity in the ischemic regions was significantly lower in patients with variant angina than in those with stable effort angina (p < 0.001). In conclusion, perfusion and washout abnormalities during exercise-induced angina are greater in patients with variant angina than in those with stable effort angina. Exercise-induced coronary spasm seems to contribute to the profound reduction in initial thallium-201 distribution and delayed thallium-201 accumulation in the ischemic region.

Facilitation of coronary spasm by propranolol in Prinzmetal's angina: fact or unproven extrapolation?

BACKGROUND

Alpha-adrenergic activation enhances coronary vascular tone; beta-blockade leaves alpha-adrenergic vasoconstriction unopposed. Whether beta-adrenergic blockade facilitates coronary spasm in patients with Prinzmetal's angina is unknown.

METHODS

Using quantitative angiography, we evaluated the response of normal and narrowed coronary arteries to intravenous propranolol, a cold pressor test (an alpha-stimulus), and the combination of the two in 15 patients with Prinzmetal's (group 1) and in 19 with classic (group 2) angina. From measurements of heart rate, systemic and pulmonary arterial pressures, and left and right ventricular ejection times, we derived the tension-time index per minute as a measure of the oxygen need (O2 demand) of the whole heart.

RESULTS

In group 1, cold invariably constricted normal and diseased vessels, and in two patients elicited spasm at sites of significant lesions; these changes did not correlate with those in O2 demand. In group 2, the vasomotor reaction of normal and narrowed vessels in response to cold correlated with the modifications in O2 demand. After propranolol administration, (1) in normal vessels in both groups, the baseline luminal diameter varied in parallel with the changes in myocardial O2 demand; (2) narrowings in group 1 patients invariably dilated and in group 2 the caliber varied according to changes in O2 demand; (3) during cold stimulation, luminal narrowing in group 1 varied in parallel with O2 demand, and, in group 2, vessels were uniformly constricted.

CONCLUSION

These results do not support the facilitation of coronary spasm by propranolol in Prinzmetal's angina and support the hypothesis that the contractility of coronary vessels in patients with this form of angina is different from that in the classic form.

Temporal variability and correlation with geometric parameters in vasospastic angina: a quantitative angiographic study

Long-term changes in vasocontractility were examined in 23 coronary segments from 20 patients with variant angina using computer-based quantitative coronary angiography and ergonovine provocation tests repeated at an interval of 42 +/- 14 months. Measurements of vasospasticity at the sites of fixed stenoses were compared with values predicted by an elementary geometric theory based on the assumption that the cross-sectional area of a vessel wall is constant regardless of its state of vasoconstriction. While all patients were symptomatic initially, only 11 remained symptomatic at follow-up. At the initial provocation test, the response was correctly predicted in four segments, was lower than expected in one, and was stronger in 18. At follow-up, only one of the four segments in which the response had been initially predicted correctly again showed the predicted response and the remaining three showed a response weaker than expected; the one segment which was initially hypocontractile remained hypocontractile at follow-up; and of the 18 segments which were initially hypercontractile, 12 exhibited hypercontractility again, four had the predicted value and the remaining two showed hypocontractility. In only one of 23 segments did the geometric theory predict the behaviour of vasospasticity at the site of fixed stenosis on both tests. Vasospastic responsiveness is a dynamic process demonstrating temporal variability and is not directly predicted by geometric theory.

[Successful documentation by coronary angiography of spontaneous simultaneous multivessel coronary spasm in a variant angina patient: a case report]

A 59-year old female who complained of chest discomfort was admitted to our hospital. Electrocardiogram (ECG) on admission and treadmill exercise test showed negative for ischemia. She underwent coronary arteriography. Initial angiography showed there was no significant coronary arterial stenosis. However, when we were preparing the spasm provocation test, she complained of the same kind of chest discomfort as she had felt before. We found that ST segment was elevated in both the anterior and inferior leads on the ECG. Coronary arteriography showed that severe spasm occurred in both the left anterior descending artery (Seg. 6) and the right coronary artery (Seg. 1). Heart rate decreased and electromechanical dissociation occurred. She temporarily lost consciousness. After cardiopulmonary resuscitation, she recovered and the elevation of ST segment returned on the ECG. This is the first case report which has documented spontaneous simultaneous multivessel coronary spasm by coronary arteriography.

Hyperventilation-echocardiography test for the diagnosis of myocardial ischaemia at rest

The purpose of this study was to assess the feasibility, safety, specificity and sensitivity of the hyperventilation test performed under echocardiographic monitoring for the provocation of vasospastic ischaemia. Hyperventilation (approximately 30 cycles.min-1 for 5 min) was performed in 104 hospitalized patients, referred for pain typical of angina at rest, under 2-D echocardiographic and 12-lead electrocardiographic monitoring. All the tests were completed and no significant side effect was observed. In-hospital documentation of spontaneous myocardial ischaemia and/or ergonovine-induced ischaemia was achieved in 38 patients (group I). A positive hyperventilation-echocardiography test (occurrence of new transient asynergies or worsening of basal ones) was obtained in 32/38 patients. Among the group I patients, only 23 had diagnostic ST-T changes and only 16 experienced chest pain during the hyperventilation-echo test. Of the 66 patients without evidence of myocardial ischaemia at rest (negative ECG monitoring during hospitalization and/or negative ergonovine maleate-echo test)--Group II, none showed echocardiographic changes, seven presented ST-T changes and six complained of typical chest pain during the test. Thus, in relation to in-hospital documentation of myocardial ischaemia at rest, both spontaneous and/or ergonovine-induced episodes, the hyperventilation-echo test showed a specificity of 100%, a sensitivity of 84%, a positive predictive value of 100% and a negative predictive value of 92%. In conclusion, hyperventilation performed under echocardiographic monitoring is feasible and safe; it can be proposed as a screening test to unmask vasospastic myocardial ischaemia in patients with angina at rest, in whom documentation of spontaneous episodes is not available.

[The use of echocardiography in examining patients with unstable stenocardia]

The report presents the results of EchoCG study in 81 patients with unstable stenocardia admitted in 6-24 hours from the onslaught pain. With the help of EchoCG the myocardial contractile function was defined and the segmental kinetics of left ventricular wall was registered with respect to four variants of unstable stenocardia courses: stenocardia occurred for the first time, progressive stenocardia, variational stenocardia and postmyocardial infarction stenocardia. During the EchoCG examination at the moment of anginal attack the significant increase in left ventricular end-diastolic volume and end-systolic volume and decrease of total ejection fraction were noted. Also, not infrequently the zones of dyskinesia are recorded indicative of ischemia of these segments, which commonly have transient character. With the progress of myocardial ischemia the abnormalities of left ventricular diastolic fraction appear which are determined with the help of Doppler-EchoCG. Thus, the use of EchoCG in diagnostics of patients with unstable stenocardia allows more reliably to define the degree of myocardial changes.

Efficacy of isosorbide-5-mononitrate versus nifedipine in preventing spontaneous and ergonovine-induced myocardial ischaemia. A double-blind, placebo-controlled study

This study was designed to assess the efficacy of oral nifedipine as compared to oral isosorbide-5-mononitrate in the prevention of spontaneous and induced vasospastic myocardial ischaemia. Twenty-one patients admitted to the Coronary Care Unit as a result of angina at rest underwent both Holter monitoring and an echo-ergonovine test during placebo and following either isosorbide-5-mononitrate or nifedipine according to a double-blind randomized trial. Both drugs caused a statistically significant reduction in spontaneous (87% and 95%, respectively) and induced ischaemic attacks (66% and 75%, respectively). No significant difference was found between the two drugs.

Cardiac arrest and sudden unexpected death in variant angina: complications of coronary spasm that can occur in the absence of severe organic coronary stenosis

Experiences in 81 patients with variant angina were reviewed with the goal of determining which clinical features were associated with the greatest risk of angina-linked cardiac arrest (13 patients) or sudden unexpected death (9 patients). The risk of occurrence of one of these actually or potentially fatal events was approximately tripled by the presence of either a history of angina-linked syncope or documentation of serious arrhythmia complicating attacks. An unexpected finding was that the risk was increased 1.5-fold by the absence of high-grade organic coronary stenosis. Cardiac arrest and sudden death are important risks of variant angina, which can occur without the presence of severe organic coronary stenosis. These risks can be reduced by adequate vasodilator therapy that includes a calcium channel blocker.

Increased echodensity of transiently asynergic myocardium in humans: a novel echocardiographic sign of myocardial ischemia

OBJECTIVES

This study was conducted to establish whether changes in myocardial texture can be observed in humans by transthoracic echocardiography during ischemic episodes of different severity and duration induced by various pathogenetic mechanisms.

BACKGROUND

Increased echo-reflectivity of ischemic myocardium has been detected in experimental animals by epicardial echocardiography and by backscatter evaluation.

METHODS

Transthoracic two-dimensional echocardiographic monitoring with a commercially available electronic sector scanner (2.25- or 3.5-MHz transducer) was performed during 35 episodes of transient myocardial ischemia induced by ergonovine in patients with vasospastic angina (n = 9), by dipyridamole in patients with angiographically assessed coronary artery disease (n = 11) and by balloon occlusion during coronary angioplasty (n = 15). Quantitative texture analysis of gray levels was performed off-line on digitized images during rest conditions, ischemia and the recovery phase in regions showing normal contraction at rest, obvious dyssynergy during ischemia and normal contraction in the recovery phase. In each condition, a control region with normal contraction throughout the study was also evaluated.

RESULTS

Chest pain occurred in 23 of the 35 episodes; electrocardiographic (ECG) changes were present in 26 episodes, and consisted of ST segment elevation in 13, ST segment depression in 10 and pseudonormalization of a basally negative T wave in 3. The duration of ischemic episodes was 67 +/- 53 s by symptomatic criteria and 91 +/- 52 s by ECG criteria. The risk region showed an increased end-diastolic mean gray level amplitude in a.u. (arbitrary units) during ischemia (57 +/- 19) compared with rest (38 +/- 15) and recovery (38 +/- 18, p < 0.01). No significant changes were detected in the control region (rest 36 +/- 16 vs. ischemia 34 +/- 18 vs. recovery 31 +/- 13, p = NS). The percent increase in mean gray level was similar in the various types of stress employed (ergonovine, dipyridamole or angioplasty) and was not significantly correlated with either the duration of ST segment shift (r = 0.05, p = NS) or the severity of dyssynergy evaluated semiquantitatively by means of the wall motion score (r = 0.28, p = NS). In the 15 balloon occlusions performed in six patients during coronary angioplasty, the increased echoreflectivity of the risk zone was already evident during echocardiographic sampling performed after 10 +/- 4 s of occlusion (rest 35 +/- 9 vs. 53 +/- 10 a.u., p < 0.01) when no dyssynergy could be detected by quantitative wall motion analysis (percent area change by fixed center of mass reference system 31 +/- 10% at rest vs. 32 +/- 11% after 10 s of occlusion, p = NS).

CONCLUSIONS

Transient short-lasting myocardial ischemia is associated with an abrupt increase in myocardial echodensity detectable by videodensitometric analysis applied to standard transthoracic echocardiographic images and is largely independent of the underlying pathogenetic mechanism (reduced blood supply or flow maldistribution with coronary stenosis). During controlled coronary occlusion, increased echodensity precedes the onset of regional dyssynergy.

Endothelium-dependent dilator response to substance P in patients with coronary spastic angina

OBJECTIVE

This study was designed to examine whether patients with coronary spastic angina have an impaired coronary artery dilator response to substance P, an endothelium-dependent vasodilator.

BACKGROUND

Impairment of the endothelium-dependent vasodilator response has been suggested to be involved in the pathogenesis of coronary spasm.

METHODS

In 11 patients with coronary spastic angina and 11 control patients, substance P was infused into the coronary artery at 20 pmol/min for 5 min. Incremental doses of acetylcholine were then injected into the coronary artery. The effects of these drugs and nitroglycerin on the coronary artery diameter were quantitatively analyzed.

RESULTS

Heart rate, systolic blood pressure and rate-pressure product did not change after substance P infusion. In 12 coronary arteries of the patients with coronary spastic angina, spasm was induced with acetylcholine. At the site of coronary spasm documented, the lumen diameter, which was 1.6 +/- 0.5 mm at baseline, increased to 2.1 +/- 0.7 mm after substance P infusion (p less than 0.01). It decreased to 0.2 +/- 0.3 mm during acetylcholine-induced spasm (p less than 0.001) and increased to 2.3 +/- 0.8 mm after nitroglycerin administration (p less than 0.001 vs. baseline and p = NS vs. after substance P infusion). Of the 12 arteries with spasm, 5 were angiographically normal and the other 7 were minimally or moderately atherosclerotic: the diameter change after substance P was +28 +/- 20% and +30 +/- 22%, respectively (p = NS). In control patients, the diameter of the middle portion of the left anterior descending artery, which was 2.0 +/- 0.4 mm at baseline, increased to 2.5 +/- 0.4 mm after substance P infusion (p less than 0.001). The diameter changes after substance P infusion were not different between the patients with coronary spastic angina and control patients.

CONCLUSIONS

Substance P dilated the artery with spasm of the patients with coronary spastic angina to a degree similar to that in control patients, indicating the preserved endothelium-dependent dilator response at the site of coronary spasm by way of substance P receptor.

Effect of ketanserin on proximal and distal coronary constrictor responses to intracoronary infusion of serotonin in patients with stable angina, patients with variant angina, and control patients

BACKGROUND

Serotonin, released by aggregating platelets, may contribute to or cause myocardial ischemia by constricting epicardial vessels. Experimental studies suggest that this constriction is mediated by two distinct serotonin receptor subtypes: 5-hydroxytryptamine1-like (S1-like) and 5-hydroxytryptamine2 (S2).

METHODS AND RESULTS

To determine the relative contribution of S1-like and S2 receptors to the vasoconstrictor effects of serotonin, we studied the effect of ketanserin (0.75 mg, intracoronary), a selective S2 receptor antagonist, on the constrictor response of human coronary vessels to intracoronary infusions of serotonin. In control patients (n = 7), serotonin (10(-4) mol/l) caused significant (p less than 0.05) constriction only in distal segments, which was significantly (p less than 0.05) inhibited by ketanserin. In stable angina patients (n = 8), serotonin (10(-4) mol/l) caused significant constriction in proximal (p less than 0.01) and distal (p less than 0.01) segments, which was significantly inhibited by ketanserin in proximal (p less than 0.05) but not distal (p = 0.30) segments. In patients with variant angina (n = 3), epicardial occlusion at the site of preexisting stenoses in proximal locations occurred at infused concentrations of 10(-6) (one patient) or 10(-5) (two patients) mol/l. The infusion of the same concentration of serotonin after ketanserin again caused epicardial occlusion.

CONCLUSIONS

Our results suggest that functionally important S1-like receptors that mediate vasoconstriction exist in the epicardial vessels of patients with stable or variant angina. Their activation, either at hyperreactive sites in patients with variant angina or in the distal epicardial vessels of patients with chronic stable angina, may contribute to or cause myocardial ischemia when serotonin is released after the intracoronary activation of platelets.

Long-term study of recurrent vasospastic angina using coronary angiograms during ergonovine provocation tests

Chronologic changes of coronary spasm were examined by repeated ergonovine provocation tests during angiography. A total of 322 patients who had variant angina without severe atherosclerosis demonstrated a positive response to the first test. Ninety of these patients had recurrent variant anginal symptoms after an angina-free period of 38 +/- 12 months (mean +/- SD). Of these 90 patients, 76 (84%) had symptoms or electrocardiographic (ECG) findings similar to those of the first test. The initial 9 of these 76 patients underwent a second provocation test and showed coronary responses analogous to those on the first test. Of the 90 patients, 14 (16%) had different symptoms or ECG findings from those elicited at the first episode. All 14 patients again had a positive response to a second ergonovine test and the following angiographic changes were observed in the three major vessels between the two tests. Of the 21 vessels that had spasm on the first test, eight vessels (19%) did not have spasm on the second test. Of the 21 vessels that did not demonstrate spasm on the first test, 10 (24%) demonstrated spasm on the second test. In the present study it is concluded that the majority of patients with recurrent angina seemed to have consistency in the location of coronary spasm, while in some patients the fluctuation of coronary spasm was confirmed by two ergonovine provocation tests.

Preservation of endothelium-dependent vasodilation in the spastic segment of the human epicardial coronary artery by substance P

The objective of this study was to determine if endothelium-dependent vasodilation is preserved in the spastic segment of the epicardial coronary artery. Segmental responses of the coronary artery to substance P were examined by the use of a quantitative angiographic technique in 21 patients with variant angina. Coronary diameter at the basal state did not differ between the spastic and the nonspastic segments (2.3 +/- 0.2 mm, 2.3 +/- 0.4 mm, p greater than 0.05). Changes in coronary diameter in response to substance P did not differ between segments with ergonovine-induced spasm and nonspastic segments. Maximal dilation averaged 27.1 +/- 9.5% in the spastic segment and 24.4 +/- 9.6% in the nonspastic segment (expressed as a percent increase over the value before drug administration). It appears that both the potential of the endothelium to release endothelium-dependent relaxing factor and the dilating response of the smooth muscle to endothelium-dependent relaxing factor are preserved, even in the spastic segment.