Refractory vasospasm with a malignant course

Refractory coronary vasospasm and recurrent cardiac arrest

We present a case of recurrent vasospasm as an uncommon cause of ventricular fibrillation in a young female patient who was found to have a genetic mutation of unknown significance in the desmoplakin (DSP) gene and ultimately required an implantable cardiac defibrillator and percutaneous coronary intervention. Refractory vasospasm as a cause of chest pain and cardiac arrest may be under-recognised. In this manuscript, we highlight the natural history of refractory vasospasm, treatment considerations including medical therapy, implantable cardiac defibrillator and percutaneous coronary intervention. Lastly, we explore the potential correlation between the DSP mutation and her clinical presentation and the growing importance of genetic testing in unexplained cardiac arrest.

Ergonovine test in angina with normal coronary arteries. Is it worth doing it?

BACKGROUND

Patients with angina and normal coronary arteries are often misdiagnosed with having non-cardiac pain. Although vasospasm is a well-known entity, spasm provocation is not routinely done in the majority of hospitals at present.

MATERIALS AND METHODS

One hundred and sixty two consecutive patients with thoracic pain and normal coronary arteries were retrospectively studied. The characteristics of pain were analysed. One hundred and sixty one non-invasive tests (with and without imaging) were done to 126 patients before angiography. Increasing doses of ergonovine (from 1 to 30 microg) were injected into the coronary arteries to provoke coronary spasm. The correlation between ergonovine-induced spasm and non-invasive tests was studied.

RESULTS

Oppressive thoracic pain suggestive of angina was present in 144 patients. It occurred at rest in 59 patients, only at night in 14, with effort in 40, and it was mixed in 31. Non-oppressive atypical pain was reported by 18 patients. Non-invasive tests were 94 positive, 60 negative and 7 non-diagnostic. Ergonovine test elicited coronary spasm in 85 patients (52.5%). No significant correlation was found between the positivity of a non-invasive test and ergonovine-induced spasm.

CONCLUSIONS

More than half of the patients with angina and normal coronary arteries can be diagnosed with vasospastic angina if ergonovine test is performed. Even patients with a negative non-invasive test maybe sent to coronary angiography when vasospastic angina is suspected, in order to have an accurate diagnosis.

Comparable prognostic value of vasodilator response to acetylcholine in brachial and coronary arteries for predicting long-term cardiovascular events in suspected coronary artery disease

BACKGROUND

Vasodilator response to acetylcholine (ACh) (ie, endothelium-dependent dilation) is impaired in the peripheral and coronary circulation of patients with coronary risk factors and coronary artery disease (CAD). There is a close relationship of vasodilator response to ACh in both the coronary artery (CA) and the brachial artery (BA), but the comparative prognostic importance of these responses has not been fully investigated in relatively low-risk suspected CAD.

METHODS AND RESULTS

The flow responses of both the CA and BA were measured in 70 patients with suspected CAD, excluding patients with triple-vessel disease and known peripheral or cerebrovascular disorders. A Doppler guidewire was placed into a major branch of the CA and a proximal portion of the left BA. ACh was infused at 10(-8), 10(-7) and 10(-6) mol/L for 3 min into the CA and at 7.5, 15, and 30 mug/min for 5 min into BA. The flow response was obtained by multiplying the average peak velocity by the cross-sectional area from quantitative angiography. Vasodilator response to ACh was assessed by the ratio of ACh-induced flow/baseline flow, expressed as coronary blood flow index (CBFI) or brachial blood flow index (BBFI). There were 39 CAD patients (61 +/- 8 years old) and 31 normal coronary patients (NL, 58 +/- 11 years old) who were followed up for 53 +/- 17 months. Eleven patients had coronary events (CE) during this period: 1 case of nonfatal myocardial infarction and 10 cases of unstable angina. A strong correlation between CBFI and BBFI was observed at middle-and high-doses of ACh (r=0.72, p<0.0001, 15 microg/min vs 10(-7) mol/L; r=0.76, p<0.0001, 30 microg/min vs 10(-6) mol/L). Kaplan-Meier analysis, using the best cut-off values obtained from receiver-operating characteristic curves for CE, revealed that both CBFI and CAFI were significant predictors for CE.

CONCLUSIONS

The BA vasodilator response to optimal ACh dosage can be used as a surrogate prognostic predictor for coronary endothelial function tests in patients with suspected CAD.

Endothelin-1 promotes Ca2+ antagonist-insensitive coronary smooth muscle contraction via activation of epsilon-protein kinase C

Certain forms of coronary artery disease do not respond to treatment with Ca2+ channel blockers, and a role for endothelin-1 (ET-1) in Ca2+ antagonist-insensitive forms of coronary vasospasm has been suggested; however, the signaling mechanisms involved are unclear. We tested the hypothesis that a component of ET-1-induced coronary smooth muscle contraction is Ca2+ antagonist-insensitive and involves activation of protein kinase C (PKC). Cell contraction was measured in smooth muscle cells isolated from porcine coronary artery, [Ca2+]i was measured in fura-2 loaded cells, and the cytosolic and particulate fractions were examined for PKC activity and reactivity with isoform-specific PKC antibodies using Western blot analysis. In Hank's solution (1 mmol/L Ca2+), ET-1 (10(-7) mol/L) caused a transient increase in [Ca2+]i (236+/-14 nmol/L) followed by a maintained increase in [Ca2+]i (184+/-8 nmol/L) and 35% cell contraction. The Ca2+ channel blockers verapamil and diltiazem (10(-6) mol/L) abolished the maintained ET-1-induced [Ca2+]i, but only partially inhibited ET-1-induced cell contraction to 18%. The verapamil-insensitive component of ET-1 contraction was inhibited by the PKC inhibitors calphostin C and epsilon-PKCV1-2. ET-1 caused translocation of Ca2+-dependent alpha-PKC and Ca2+-independent epsilon-PKC from the cytosolic to the particulate fraction that was inhibited by calphostin C. Verapamil abolished ET-1-induced translocation of alpha-PKC, but not that of epsilon-PKC. Phorbol 12-myristate 13-acetate (10(-6) mol/L), a direct activator of PKC, caused 22% cell contraction, with no increase in [Ca2+]i, and translocation of epsilon-PKC that was inhibited by calphostin C, but not by verapamil. KCl (51 mmol/L), which stimulates Ca2+ influx, caused 35% cell contraction and increase in [Ca2+]i (291+/-11 nmol/L) that were inhibited by verapamil, but not by calphostin C, and did not cause translocation of alpha- or epsilon-PKC. In Ca2+-free (2 mmol/L EGTA) Hank's solution, ET-1 caused 15% cell contraction, with no increase in [Ca2+]i, and translocation of epsilon-PKC that were inhibited by epsilon-PKC V1-2 inhibitory peptide. Thus, a significant component of ET-1-induced contraction of coronary smooth muscle is Ca2+ antagonist-insensitive and involves activation and translocation of Ca2+-independent epsilon-PKC, and may represent a signaling mechanism of Ca2+ antagonist-resistant forms of coronary vasospasm.

Ca2+ antagonist-insensitive coronary smooth muscle contraction involves activation of ϵ-protein kinase C-dependent pathway

Certain angina and coronary artery disease forms do not respond to Ca2+ channel blockers, and a role for vasoactive eicosanoids such as PGF2α in Ca2+ antagonist-insensitive coronary vasospasm is suggested; however, the signaling mechanisms are unclear. We investigated whether PGF2α-induced coronary smooth muscle contraction is Ca2+ antagonist insensitive and involves activation of a PKC-dependent pathway. We measured contraction in single porcine coronary artery smooth muscle cells and intracellular free Ca2+ concentration ([Ca2+]i) in fura 2-loaded cells and examined cytosolic and particulate fractions for PKC activity and reactivity with isoform-specific PKC antibodies. In Hanks' solution (1 mM Ca2+), PGF2α (10-5 M) caused transient [Ca2+]i increase followed by maintained [Ca2+]i increase and 34% cell contraction. Ca2+ channel blockers verapamil and diltiazem (10-6 M) abolished maintained PGF2α-induced [Ca2+]i increase but only partially inhibited PGF2α-induced cell contraction to 17%. Verapamil-insensitive PGF2α contraction was inhibited by PKC inhibitors GF-109203X, calphostin C, and ϵ-PKC V1-2. PGF2α caused Ca2+-dependent α-PKC and Ca2+-independent ϵ-PKC translocation from cytosolic to particulate fractions that was inhibited by calphostin C. Verapamil abolished PGF2α-induced α-but not ϵ-PKC translocation. PMA (10-6 M), a direct activator of PKC, caused 21% contraction with no significant [Ca2+]i increase and ϵ-PKC translocation that were inhibited by calphostin C but not verapamil. Membrane depolarization by 51 mM KCl, which stimulates Ca2+ influx, caused 36% cell contraction and [Ca2+]i increase that were inhibited by verapamil but not GF-109203X or calphostin C and did not cause α- or ϵ-PKC translocation. Thus a significant component of PGF2α-induced contraction of coronary smooth muscle is Ca2+ antagonist insensitive, involves Ca2+-independent ϵ-PKC activation and translocation, and may represent a signaling mechanism of Ca2+ antagonist-resistant coronary vasospasm.