Stent implantation in variant angina refractory to medical treatment

Girl Who Cried Wolf: A Case of Prinzmetal Angina With Related ST-Elevation Myocardial Infarction

Prinzmetal variant angina is characterized by episodic chest pain associated with transient ST changes seen on an electrocardiogram (EKG). A 51-year-old female with a pertinent history of non-obstructive coronary artery disease (CAD), non-ST elevation myocardial infarction (NSTEMI) twice, ST-elevation myocardial infarction (STEMI), Prinzmetal angina, ventricular tachycardia s/p implantable cardioverter-defibrillator placement, and gastroesophageal reflux disease presented with 2.5 hours of left-sided chest pain with radiation to the left arm. Her initial EKG was not revealing. However, a subsequent EKG showed ST elevations in the inferior leads. A coronary angiogram was performed and revealed distal right coronary artery spasm that was relieved with intracoronary nitroglycerin. The nature of her chest pain in conjunction with her EKG and angiogram findings helped diagnose her with Prinzmetal angina that was significant enough to result in a STEMI. Thus, Prinzmetal angina and STEMI can be interconnected rather than being separate, mutually exclusive pathologies.

Sympathectomy versus conventional treatment for refractory coronary artery spasm

BACKGROUND

There is no clear consensus on the potential efficacy and indications for sympathectomy to prevent recurrence of vasospasm in patients with refractory coronary artery spasm (CAS).

OBJECTIVE

To compare the clinical outcomes of sympathectomy with those of conventional treatment in patients with refractory CAS.

PATIENTS AND METHODS

Patients with refractory CAS were randomly assigned to sympathectomy group (n = 37) or conventional treatment group (n = 42). The primary end point was a composite of major adverse cardiac event (MACE) episodes (including cardiac death, nonfatal myocardial infarction, unstable angina, heart failure, and life-threatening arrhythmia), and the secondary end point was death from any cause within 24 months after randomization.

RESULTS

During the follow-up period of 24 months, the incidence of MACE in the sympathectomy and conventional treatment groups was 16.22 and 61.90%, respectively (P = 0.0001). All-cause death as the secondary end point occurred in zero and six (14.29%) patients, respectively (P = 0.0272). The Kaplan-Meier curve for MACE and all-cause death showed a significant between-group difference (log-rank test, P = 0.0013 and 0.0176, respectively).

CONCLUSION

Compared with conventional treatment, sympathectomy significantly reduced the composite end point of MACE episodes and death from any cause in patients with refractory CAS by effectively preventing recurrence of vasospasm.

Fatal Multi-Vessel Coronary Vasospasm: A Case Report

We report a case of a 59-year-old female who experienced a history of an acute ST myocardial infarction. Percutaneous intervention and isosorbide dinitrate perfusion were successful in reversing the severe vasospasm on the left anterior descending, the first diagonal, and posterior interventricular arteries. The patient received calcium channel blockers and nitrates with a good in-hospital clinical evolution. One month later, the patient presented to the ED with chest pain leading to cardiac arrest despite cardiopulmonary resuscitation. This case highlights the fatal outcome of coronary artery vasospasm.

Intravascular ultrasound findings and stent implantation for a patient with coronary spastic angina at site of progressive atherosclerotic plaque and responded poorly to medical treatment: a case report

BACKGROUND

Most coronary spastic angina patients are responsive to coronary vasodilators therapy, and stent implantation is not recommended for regular use. We reported the angiographic and intravascular ultrasound (IVUS) images of a rare case who responded poorly to medical treatment due to progressive atherosclerotic plaque at the spastic site.

CASE PRESENTATION

A 60-year-old man complaining of 1-month history of episodic chest pain at rest was admitted to our hospital. The diagnosis of coronary spastic angina was made based on the angiographic evidence of vasospasm at the right coronary artery (RCA). The patient responded poorly to conventional medical treatment during the 1-year follow-up. The repeated angiography revealed totally occlusion of the proximal segment of the RCA at the same location as 1 year before, and IVUS demonstrated there was vulnerable plaque and thrombus at the site of spasm. Episodic chest pain ceased completely in the follow up period after stenting.

CONCLUSION

Coronary spasm might present at the vessel site with advanced atherosclerotic plaque. For patients with refractory vasospastic angina and significant occlusion, stenting might be a viable and valuable treatment strategy under the guidance of intracoronary imaging.

How to Diagnose and Manage Angina Without Obstructive Coronary Artery Disease: Lessons from the British Heart Foundation CorMicA Trial

Patients with symptoms and/or signs of ischaemia but no obstructive coronary artery disease (INOCA) present a diagnostic and therapeutic challenge. Microvascular and/or vasospastic angina are the two most common causes of INOCA; however, invasive coronary angiography lacks the sensitivity to diagnose these functional coronary disorders. In this article, the authors summarise the rationale for invasive testing in the absence of obstructive coronary disease, namely that correct treatment for angina patients starts with the correct diagnosis. They provide insights from the CORonary MICrovascular Angina (CorMicA) study, where an interventional diagnostic procedure was performed with linked medical therapy to improve patient health. Identification of these distinct disorders (microvascular angina, vasospastic angina or non-cardiac chest pain) is key for stratifying INOCA patients, allowing prognostic insights and better patient care with linked therapy based on contemporary guidelines. Finally, they propose a framework to diagnose and manage patients in this common clinical scenario.

Variant angina in chronic kidney disease: a case report of an unusual presentation of cardiac arrest following dialysis

Variant angina (VA) is described as a relatively benign syndrome of unprovoked chest pain and electrocardiographic (ECG) changes. Chronic kidney disease (CKD) may be associated with this syndrome. However, the incidence of severe manifestations of VA in this patient cohort with kidney disease has not been elucidated. Also, no description has been made of coronary vasospam in relation to dialysis sessions. Our patient, a young female with CKD, had an unusual history of angina following dialysis sessions and she suffered an acute coronary syndrome complicated by cardiac arrest. The diagnosis was made on the basis of her clinical features, dynamic ECG changes, and coronary angiogram findings, and the patient was managed medically. Severe manifestations of VA may occur in chronic kidney disease, and this should be kept in mind by the treating physician. The association of coronary vasospasm with dialysis needs further analysis.

Exercise-induced saphenous vein graft spasm prevented by stenting

Recurrence of anginal symptoms following coronary artery bypass surgery is usually secondary to graft closure or progression of native vessel disease. The present case demonstrates severe exercise-induced saphenous vein graft (SVG) spasm associated with transmural ischemia refractory to maximal vasodilator therapy. Symptoms resolved and exercise electrocardiography normalized following stenting of SVG regions demonstrating spasm. © 2017 Wiley Periodicals, Inc.

Coronary artery spasm: Current knowledge and residual uncertainties

Myocardial ischaemia results from a direct mismatch between oxygen supply and demand, commonly arising as a result of coronary atherosclerosis, microvascular dysfunction or acute thrombosis and luminal obstruction. However, transient ischaemia may also occur due to coronary spasm leading to acute and unexpected myocardial ischaemia without obvious visible coronary pathology. Aside from symptoms of chest pain, coronary spasm can cause infarction, LV impairment, promote life threatening arrhythmias and ultimately sudden cardiac death. While therapeutic options are available, controversies exist around diagnosis, pathology, management and prognosis. This review summarises some of the common questions in this area. In particular we explore and discuss the available evidence for the pharmacological treatment of coronary spasm, and strategies for identification and management of very high risk patients to try and reduce the incidence of sudden premature death.

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Myocardial ischaemia results from a mismatch between oxygen supply and demand.

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Spasm might lead to myocardial ischaemia without visible coronary pathology.

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Coronary spasm can cause infarction, LV impairment and sudden cardiac death.

Successful treatment using corticosteroids in a patient with refractory vasospastic angina and bronchial asthma

We report a 55-year-old female patient with refractory vasospastic angina and bronchial asthma treated successfully with corticosteroids. She was diagnosed with vasospastic angina by coronary angiography and the acetylcholine provocation test. Even after administration of oral vasodilators (benidipine, diltiazem, nicorandil, isosorbide mononitrate) she had recurrent chest pain with ST elevation. She had a history of bronchial asthma, so we added 30 mg/day of oral prednisolone. Her symptoms disappeared completely upon treatment. This case report suggests that corticosteroids are a therapeutic choice for patients with refractory vasospastic angina, especially for those with bronchial asthma. <Learning objective: We report a 55-year-old female patient with refractory vasospastic angina and bronchial asthma. Even after administration of oral vasodilators, she had recurrent chest pain with ST elevation. She had a history of bronchial asthma, so we added 30 mg/day of oral prednisolone. Her symptoms disappeared completely upon treatment. This case report suggests that corticosteroids are a therapeutic choice for patients with refractory vasospastic angina, especially for those with bronchial asthma.>.

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.