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Montone RA, Niccoli G, Fracassi F, Russo M, Gurgoglione F, Cammà G, Lanza GA, Crea F. Patients with acute myocardial infarction and non-obstructive coronary arteries: safety and prognostic relevance of invasive coronary provocative tests. Eur Heart J 2019; 39:91-98. [PMID: 29228159 DOI: 10.1093/eurheartj/ehx667] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 11/20/2017] [Indexed: 12/19/2022] Open
Abstract
Aims Functional alterations of epicardial coronary arteries or coronary microcirculation represent a frequent cause of myocardial infarction and non-obstructive coronary arteries (MINOCA). We aimed at assessing the prognostic value of intracoronary provocative tests in patients presenting with MINOCA and in which other causes of MINOCA have been excluded. Methods and results We prospectively evaluated patients with a diagnosis of MINOCA, excluding patients with aetiologies other than suspected coronary vasomotor abnormalities. Immediately after coronary angiography, an invasive provocative test using acetylcholine or ergonovine was performed. The incidence of death from any cause, cardiac death, and recurrence of acute coronary syndrome (ACS) was assessed at follow-up. We also assessed angina status using Seattle Angina Questionnaires (SAQ). We enrolled 80 consecutive patients [mean age 63.0 ± 10.7 years, 40 (50%) male]. Provocative test was positive in 37 (46.2%) patients without any complication. Among patients with a positive test, epicardial spasm was detected in 24 (64.9%) patients and microvascular spasm in 13 (35.1%) patients. After a median follow-up of 36.0 (range 12.0-60.0) months, patients with a positive test had a significantly higher occurrence of death from any cause [12 (32.4%) vs. 2 (4.7%); P = 0.002], cardiac death [7 (18.9%) vs. 0 (0.0%); P = 0.005], and readmission for ACS [10 (27.0%) vs. 3 (7.0%); P = 0.015] as well as a worse angina status as assessed by SAQ [Seattle score: 88.0 (33.0-100.0) vs. 100.0 (44.0-100.0); P = 0.001] when compared with patients with a negative test. Conclusions We demonstrate that in patients presenting with MINOCA and suspected coronary vasomotor abnormalities, a positive provocative test for spasm is safe and identifies a high-risk subset of patients.
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Affiliation(s)
- Rocco A Montone
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Francesco Fracassi
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Michele Russo
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Filippo Gurgoglione
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Giulia Cammà
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Gaetano A Lanza
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, L.go A. Gemelli, 8, 00168 Rome, Italy
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Park TK, Gwag HB, Park SJ, Park H, Kang D, Park J, Cho J, Chung CR, Jeon K, Suh GY, Guallar E, Cho J, Yang JH. Differential prognosis of vasospastic angina according to presentation with sudden cardiac arrest or not: Analysis of the Korean Health Insurance Review and Assessment Service. Int J Cardiol 2018; 273:39-43. [PMID: 30282600 DOI: 10.1016/j.ijcard.2018.09.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/21/2018] [Accepted: 09/24/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND The long-term prognosis of vasospastic angina (VSA) patients presenting with aborted sudden cardiac death (ASCD) is still unknown. We sought to compare the long-term clinical outcomes between VSA patients presenting with and without ASCD by retrospective analysis of a nationwide population-based database. METHODS A total of 6972 patients in the Health Insurance Review and Assessment database who were hospitalized in the intensive care unit with VSA between July 1, 2007 and May 31, 2015 were enrolled. Primary outcome was the composite of cardiac arrest and acute myocardial infarction after discharge. RESULTS Five hundred ninety-eight (8.6%) VSA patients presented with ASCD. On inverse probability of treatment weighting, ASCD patients had a significantly increased risk of the composite of cardiac arrest and acute myocardial infarction (adjusted hazard ratio, 2.52; 95% confidence interval, 1.72-3.67; p < 0.001) during the median follow-up duration of 4 years. The association of ASCD presentation with a worse outcome in terms of primary outcome was consistent across various subgroups, including comorbidity type and use of vasodilators (all p-values for interaction: non-significant). ASCD patients treated with an implantable cardioverter defibrillator (ICD) had a lower incidence of the composite of cardiac arrest and acute myocardial infarction during follow-up than those without an ICD (p = 0.009). CONCLUSIONS VSA patients that present with ASCD are at increased risk of cardiac arrest or myocardial infarction during long-term follow-up despite adequate vasodilator therapy. An ICD is a potential therapeutic option for secondary prevention.
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Affiliation(s)
- Taek Kyu Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hye Bin Gwag
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - So Jin Park
- Department of Pharmaceutical Services, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyejeong Park
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | - Jinkyeong Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | - Eliseo Guallar
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea; Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Republic of Korea; Departments of Epidemiology and Medicine, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea; Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Sueda S, Kohno H. Relationships between more than 90% coronary luminal narrowing induced by ergonovine provocation test and ECG ischemic change as well as chest symptoms. Heart Vessels 2017; 33:95-101. [PMID: 28808762 DOI: 10.1007/s00380-017-1035-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 08/09/2017] [Indexed: 01/27/2023]
Abstract
In the clinic, patients with ≥90% luminal narrowing during ergonovine (ER) testing had variable response. We investigated ischemic findings and chest symptoms in patients with ≥90% luminal narrowing when performing ER tests, retrospectively. We performed 1210 ER tests over 26 years (1991-2016). We analyzed chest symptoms and positive ischemic ECG changes during ER tests. More than 90% luminal narrowing was found in 352 patients (29.1%) including 211 patients in the right coronary artery (RCA) and 217 patients in the left coronary artery (LCA). Chest symptom was observed in 290 patients (82.4%) including 162 patients in the RCA and 179 patients in the LCA. ST elevation was found in 154 patients including 98 in the RCA and 73 patients in the LCA, while ST depression was recognized in 81 patients including 38 patients in the RCA and 62 patients in the LCA. Two-third of patients with ≥90% luminal narrowing had significant ischemic ECG changes, whereas 60.5% of patients with ≥90% luminal narrowing complained usual chest pain accompanied with significant ischemic ECG changes. Unusual chest symptom was complained in 7.1% of patients with ≥90% luminal narrowing. Neither chest symptom nor ECG changes was found in 48 patients (13.6%) with ≥90% luminal narrowing. We should understand some limitation to diagnose positive coronary spasm during ER tests.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Hongo 3 Chome 1-1, Niihama, Ehime Prefecture, 792-0042, Japan.
| | - Hiroaki Kohno
- Department of Cardiology, Tsukazaki Hospital, Himeji, Japan
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Prognosis of Variant Angina Manifesting as Aborted Sudden Cardiac Death. J Am Coll Cardiol 2017; 68:137-45. [PMID: 27386766 DOI: 10.1016/j.jacc.2016.04.050] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 03/31/2016] [Accepted: 04/12/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The long-term prognosis of patients with variant angina presenting with aborted sudden cardiac death (ASCD) is unknown. OBJECTIVES The purpose of this study was to evaluate the long-term mortality and ventricular tachyarrhythmic events of variant angina with and without ASCD. METHODS Between March 1996 and September 2014, 188 patients with variant angina with ASCD and 1,844 patients with variant angina without ASCD were retrospectively enrolled from 13 heart centers in South Korea. The primary endpoint was cardiac death. RESULTS Predictors of ASCD manifestation included age (odd ratio [OR]: 0.980 by 1 year increase; 95% confidence interval [CI]: 0.96 to 1.00; p = 0.013), hypertension (OR: 0.51; 95% CI: 0.37 to 0.70; p < 0.001), hyperlipidemia (OR: 0.38; 95% CI: 0.25 to 0.58; p < 0.001), family history of sudden cardiac death (OR: 3.67; 95% CI: 1.27 to 10.6; p = 0.016), multivessel spasm (OR: 2.06; 95% CI: 1.33 to 3.19; p = 0.001), and left anterior descending artery spasm (OR: 1.40; 95% CI: 1.02 to 1.92; p = 0.04). Over a median follow-up of 7.5 years, the incidence of cardiac death was significantly higher in ASCD patients (24.1 per 1,000 patient-years vs. 2.7 per 1,000 patient-years; adjusted hazard ratio [HR]: 7.26; 95% CI: 4.21 to 12.5; p < 0.001). Death from any cause also occurred more frequently in ASCD patients (27.5 per 1,000 patient-years vs. 9.6 per 1,000 patient-years; adjusted HR: 3.00; 95% CI: 1.92 to 4.67; p < 0.001). The incidence rate of recurrent ventricular tachyarrhythmia in ASCD patients was 32.4 per 1,000 patient-years, and the composite of cardiac death and ventricular tachyarrhythmia was 44.9 per 1,000 patient-years. A total of 24 ASCD patients received implantable cardioverter-defibrillators (ICDs). There was a nonsignificant trend of a lower rate of cardiac death in patients with ICDs than those without ICDs (p = 0.15). CONCLUSIONS The prognosis of patients with variant angina with ASCD was worse than other patients with variant angina. In addition, our findings supported ICDs in these high-risk patients as a secondary prevention because current multiple vasodilator therapy appeared to be less optimal.
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Choi BG, Jeon SY, Rha SW, Park SH, Shim MS, Choi SY, Byun JK, Li H, Choi JY, Park EJ, Park SH, Lee JJ, Lee S, Na JO, Choi CU, Lim HE, Kim JW, Kim EJ, Park CG, Seo HS, Oh DJ. Impact of Renin-Angiotensin System Inhibitors on Long-Term Clinical Outcomes of Patients With Coronary Artery Spasm. J Am Heart Assoc 2016; 5:JAHA.116.003217. [PMID: 27444508 PMCID: PMC5015365 DOI: 10.1161/jaha.116.003217] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Coronary artery spasm (CAS) is a well‐known endothelial dysfunction, and a major cause of vasospastic angina (VSA). The renin–angiotensin system (RAS) is known to be closely associated with endothelial function. However, there are only a few studies that investigated the impact of RAS inhibitor on long‐term clinical outcomes in VSA patients. Methods and Results A total of 3349 patients with no significant coronary artery disease, diagnosed with CAS by acetylcholine provocation test were enrolled for this study. Significant CAS was defined as having ≥70% narrowing of the artery after incremental injections of 20, 50, and 100 μg of acetylcholine into the left coronary artery. Patients were divided into 2 groups according to whether the prescription included RAS inhibitor or not (RAS inhibitor group: n=666, non‐RAS inhibitor group; n=2683). To adjust for any potential confounders that could cause bias, propensity score matching (PSM) analysis was performed using a logistic regression model. After PSM analysis, 2 matched groups (524 pairs, n=1048 patients, C‐statistic=0.845) were generated and their baseline characteristics were balanced. During the 5‐year clinical follow‐up, the RAS inhibitor group showed a lower incidence of recurrent angina (8.7% versus 14.1%, P=0.027), total death (0.0% versus 1.3%, P=0.045), and total major adverse cardiovascular events (1.0% versus 4.1%, P=0.026) than the non‐RAS inhibitor group. Conclusions Chronic RAS inhibitor therapy was associated with lower incidence of cardiovascular events in VSA patients in the 5‐year clinical follow‐up.
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Affiliation(s)
- Byoung Geol Choi
- Department of Medicine, Korea University Graduate School, Seoul, Korea
| | - Sung Yeon Jeon
- Department of Medicine, Korea University Graduate School, Seoul, Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Sang-Ho Park
- Cardiology Department, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Min Suk Shim
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Se Yeon Choi
- Department of Medicine, Korea University Graduate School, Seoul, Korea
| | - Jae Kyeong Byun
- Department of Medicine, Korea University Graduate School, Seoul, Korea
| | - Hu Li
- Department of Medicine, Korea University Graduate School, Seoul, Korea
| | - Jah Yeon Choi
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Eun Jin Park
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Sung-Hun Park
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Jae Joong Lee
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Sunki Lee
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Jin Oh Na
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Cheol Ung Choi
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Hong Euy Lim
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Jin Won Kim
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Eung Ju Kim
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Chang Gyu Park
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Hong Seog Seo
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Dong Joo Oh
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
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Abstract
OBJECTIVE We examined the clinical usefulness of sequential spasm provocation tests as follows: first, acetylcholine (ACh) test, second, ergonovine (ER) test, and finally, the ACh test following the ER test. PATIENTS AND METHODS We performed the ACh and ER tests in 461 patients (294 men, 64.4±11.3 years of age) during a 23-year period. In addition, we administered an intracoronary injection of ACh after the ER tests in 240 patients. First, ACh [right coronary artery (RCA): 20/50/(80) μg, left coronary artery (LCA): 20/50/100/(200) μg] was administered incrementally over 20 s. Second, ER (RCA: 40 μg, LCA: 64 μg) was administered over 2-4 min. If a provoked spasm did not occur, we administered an intracoronary injection of ACh (50/80 μg into the RCA and 100/200 μg into the LCA) just after the ER tests. A positive spasm was defined as more than 99% transient luminal narrowing. RESULTS A positive spasm was observed in 221 (47.9%) patients including 181 ACh-positive (39.3%) and 119 ER-positive (25.8%) patients by the ACh or ER tests. In the 240 patients with a negative spasm in the ACh and ER tests, 48 (10.4%) patients developed provoked spasms on adding ACh after the ER test. The distributions of various cardiac disorders and provoked spasm vessels were similar among the three positive groups. Focal spasm was frequently observed in the ER-positive group, whereas diffuse spasm was frequently obtained in the ACh-positive group and by adding ACh after ER in the positive group. No major complications were recognized during the sequential spasm provocation tests. CONCLUSION Sequential spasm provocation tests might overcome a limitation of standard spasm provocation tests.
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Saito Y, Kitahara H, Shoji T, Tokimasa S, Nakayama T, Sugimoto K, Fujimoto Y, Kobayashi Y. Intracoronary Acetylcholine Provocation Testing – Omission of the 20-µg Dose Is Feasible in Patients Without Coronary Artery Spasm in the Other Coronary Artery –. Circ J 2016; 80:1820-3. [DOI: 10.1253/circj.cj-16-0344] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Toshihiro Shoji
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Satoshi Tokimasa
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Takashi Nakayama
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Kazumasa Sugimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yoshihide Fujimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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Sueda S, Miyoshi T, Sasaki Y, Ohshima K, Sakaue T, Habara H, Kohno H. Complete definite positive spasm on acetylcholine spasm provocation tests: comparison of clinical positive spasm. Heart Vessels 2014; 31:143-51. [PMID: 25366988 DOI: 10.1007/s00380-014-0595-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 10/17/2014] [Indexed: 02/07/2023]
Abstract
In the clinical grounds, patients with ≥90 % luminal narrowing during acetylcholine (ACh) testing had variable response. We investigated ischemic findings and chest symptoms in patients with ≥90 % luminal narrowing when performing ACh tests, retrospectively. We performed 763 ACh tests over 13 years (2001-2013). We analyzed chest symptoms and positive ischemic ECG changes during ACh tests. More than 90 % luminal narrowing was found in 441 patients (57.8 %) including 355 patients in the right coronary artery (RCA) and 363 patients in the left coronary artery (LCA). Chest symptom was observed in 386 patients (87.5 %) including 293 patients in the RCA and 304 patients in the LCA. ST elevation was found in 161 patients including 110 in the RCA and 85 patients in the LCA, while ST depression was recognized in 146 patients including 119 patients in the RCA and 117 patients in the LCA. Three quarter of patients with ≥90 % luminal narrowing had significant ischemic ECG changes, whereas two-third of patients with ≥90 % luminal narrowing complained usual chest pain accompanied with significant ischemic ECG changes. Unusual chest symptom was complained in 7.3 % patients with ≥90 % luminal narrowing. Neither chest symptom nor ECG changes were found in 30 patients (6.8 %) with ≥90 % luminal narrowing. A third of these patients had ischemic findings on non-invasive tests before catheterization and six patients had subtotal or total occlusion. We should realize some limitation to define positive coronary spasm based on the ischemic ECG change and chest symptom during ACh tests.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama City, Ehime Prefecture, 792-0042, Japan.
| | - Toru Miyoshi
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama City, Ehime Prefecture, 792-0042, Japan
| | - Yasuhiro Sasaki
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama City, Ehime Prefecture, 792-0042, Japan
| | - Kousei Ohshima
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama City, Ehime Prefecture, 792-0042, Japan
| | - Tomoki Sakaue
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama City, Ehime Prefecture, 792-0042, Japan
| | - Hirokazu Habara
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama City, Ehime Prefecture, 792-0042, Japan
| | - Hiroaki Kohno
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama City, Ehime Prefecture, 792-0042, Japan
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Sueda S, Miyoshi T, Sasaki Y, Sakaue T, Habara H, Kohno H. Safety and optimal protocol of provocation test for diagnosis of multivessel coronary spasm. Heart Vessels 2014; 31:137-42. [PMID: 25366987 DOI: 10.1007/s00380-014-0591-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/03/2014] [Indexed: 01/01/2023]
Abstract
We examined the safety of acetylcholine (ACh) and ergonovine (ER) tests retrospectively and investigated the optimal protocol of provocation test for diagnosis of multivessel coronary spasm. We performed 1546 ACh tests and 1114 ER tests during 23 years. ACh was injected in incremental doses of 20/50/80 μg into the right coronary artery (RCA) and of 20/50/100/200 μg into the left coronary artery (LCA) over 20 s. ER was administered in total doses of 40 μg into the RCA and of 64 μg into the LCA over 2-4 min. When a coronary spasm was induced and did not resolve spontaneously within 3 min after the completion of ACh/ER injection, or when hemodynamic instability due to coronary spasms occurred, 2.5-5.0 mg of nitrate was administered into the responsible vessel. To relive provoked spasm, it is necessary to administer nitrate in 31 cases by ACh and in 76 cases by ER (2.0 vs. 6.8 %, p < 0.01) before another vessel attempts. Multivessel spasms were often observed in LCA testing than in RCA testing on both agents [ACh: 78.6 % (11/14) vs. 11.8 % (2/17), p < 0.001, ER: 37.8 % (14/37) vs. 20.5 % (8/39), ns]. Even after the administration of nitrates, positive coronary spasm was obtained in 21.1 % by ACh and 52.9 % by ER tests on another coronary artery. No irreversible complications were recognized on both tests. We should firstly perform spasm provocation tests in the LCA and we may be able to diagnose another vessel spasm by performing the complete spasm provocation tests after the administration of nitrates to relieve provoked spasm in the first attempt.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan.
| | - Toru Miyoshi
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Yasuhiro Sasaki
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Tomoki Sakaue
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Hirokazu Habara
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Hiroaki Kohno
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
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Maximal acetylcholine dose of 200 μg into the left coronary artery as a spasm provocation test: comparison with 100 μg of acetylcholine. Heart Vessels 2014; 30:771-8. [PMID: 25179297 DOI: 10.1007/s00380-014-0563-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/11/2014] [Indexed: 02/07/2023]
Abstract
As a spasm provocation test of acetylcholine (ACH), incremental dose up (20/50/100 μg) into the left coronary artery (LCA) is recommended in the guidelines established by Japanese Circulation Society. Recently, Ong et al. reported the ACOVA study which maximal ACH dose was 200 μg in the LCA. We compared the angiographic findings between ACH 100 μg and ACH 200 μg in the LCA and also examined the usefulness and safety of ACH 200 μg in Japanese patients without variant angina. As a spasm provocation test, we performed intracoronary injection of ACH 200 μg after ACH 100 μg in 88 patients (55 males, 68.4 ± 11.7 years old) including 59 ischemic heart disease (IHD) patients and 29 non-IHD patients. Positive spasm was defined as >99 % transient stenosis (focal spasm) or 90 % severe diffuse vasoconstriction (diffuse spasm). Positive spasm by ACH 200 μg was significantly higher than that by ACH 100 μg (36 pts: 40.9 % vs. 17 pts: 19.3 %, p < 0.01). Diffuse distal spasm on the left anterior descending artery was more recognized in ACH 200 μg than in ACH 100 μg (30.7 vs. 13.6 %, p < 0.01). In 29 rest angina patients, positive spasm by ACH 200 μg (19 pts) was significantly higher than that by ACH 100 μg (7 pts) (65.5 vs. 24.1 %, p < 0.01). No serious irreversible complications were found during ACH 200 μg. Administration of ACH 200 μg into the LCA was safe and useful. We may reexamine the maximal ACH dose into the LCA.
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