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Sueda S, Kurokawa K, Sakaue T, Ikeda S. What is the meaning of provoked spasm phenotypes by vasoreactivity testing? J Cardiol 2024; 83:1-7. [PMID: 37453595 DOI: 10.1016/j.jjcc.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/15/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
Coronary artery epicardial spasm is involved in the pathogenesis of many cardiac disorders. Vasoreactivity testing, such as intracoronary injection of acetylcholine (ACH) or ergonovine (ER), is the gold standard method for the diagnosis of vasospastic angina. Provoked epicardial spasm phenotypes are classified as focal spasm and diffuse spasm. Multiple factors, including sex, ethnicity, and use of coronary vasoactive stimulators, are related to the provoked phenotypes of epicardial spasm. Diffuse-provoked spasm is often observed in females, where focal-provoked spasm is markedly more common in males. ACH provokes more diffuse and distal spasms, whereas ER induces more focal and proximal spasms. Yellow plaque and coronary thrombi are often observed in lesions with focal spasms, and intimal thickness with a sonolucent zone is significantly more common in lesions with focal spasm. Furthermore, clinical outcomes in patients with focal spasm are unsatisfactory compared with those in patients with diffuse spasm. However, the reproducibility and eternality of provoked spasm phenotypes by vasoreactivity testing is uncertain. Coronary atherosclerosis or endothelial damage may affect coronary vasomotor tone. Although coronary artery spasm may persist in the same coronary artery, provoked coronary spasm phenotypes may exhibit a momentary coronary reaction by intracoronary ACH or ER testing.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Toon City, Japan; Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama City, Japan.
| | - Keisho Kurokawa
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama City, Japan
| | - Tomoki Sakaue
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Toon City, Japan
| | - Shuntaro Ikeda
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Toon City, Japan
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Picard F, Adjedj J, Collet JP, Van Belle E, Monsegu J, Karsenty B, Dupouy P, Quillot M, Bonnet G, Gautier A, Cayla G, Benamer H. Pharmacological coronary spasm provocative testing in clinical practice: A French Coronary Atheroma and Interventional Cardiology Group (GACI) position paper. Arch Cardiovasc Dis 2023; 116:590-596. [PMID: 37891058 DOI: 10.1016/j.acvd.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023]
Abstract
Vasospastic angina, also described as Prinzmetal angina, was first described as a variant form of angina at rest with transient ST-segment elevation; it is common and present in many clinical scenarios, including chronic and acute coronary syndromes, sudden cardiac death, arrhythmia and syncope. However, vasospastic angina remains underdiagnosed, and provocative tests are rarely performed. The gold-standard diagnostic approach uses invasive coronary angiography to induce coronary spasm using ergonovine, methylergonovine or acetylcholine as provocative stimuli. The lack of uniform protocol decreases the use and performance of these tests, accounting for vasospastic angina underestimation. This position paper from the French Coronary Atheroma and Interventional Cardiology Group (GACI) aims to review the indications for provocative tests, the testing conditions, drug protocols and positivity criteria.
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Affiliation(s)
- Fabien Picard
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France.
| | - Julien Adjedj
- Department of Cardiology, Institut Arnault-Tzanck, 06700 Saint-Laurent-du-Var, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, AP-HP, 75013 Paris, France
| | - Eric Van Belle
- CHU Lille, Department of Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Institut Coeur Poumon, INSERM U1011, Institut Pasteur de Lille, EGID, Université de Lille, 59000 Lille, France
| | - Jacques Monsegu
- Department of Interventional Cardiology, Institut Cardio-Vasculaire, Groupe Hospitalier Mutualiste Grenoble, 38000 Grenoble, France
| | | | - Patrick Dupouy
- Pôle Cardio-Vasculaire Interventionnel, Clinique les Fontaines, 77000 Melun, France
| | - Marine Quillot
- Department of Interventional Cardiology, Centre Hospitalier Henri-Duffaut, 84000 Avignon, France
| | - Guillaume Bonnet
- Haut-Lévêque Cardiology Hospital, Bordeaux University, 33600 Pessac, France
| | - Alexandre Gautier
- Department of Cardiology, Hôpital Bichat, AP-HP, 75018 Paris, France
| | - Guillaume Cayla
- Cardiology Department, Nîmes University Hospital, Montpellier University, 30900 Nîmes, France
| | - Hakim Benamer
- ICPS Jacques Cartier, Ramsay Générale de Santé, 91300 Massy, France; ICV-GVM La Roseraie, 93300 Aubervilliers, France; Hôpital Foch, 92150 Suresnes, France
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Sueda S, Sakaue T. Sex-related differences in coronary vasomotor disorders: Comparisons between Western and Japanese populations. J Cardiol 2023; 81:161-167. [PMID: 35534347 DOI: 10.1016/j.jjcc.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/19/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
Sex-related differences in the prevalence of cardiac disorders have been elucidated beyond races. Angina/ischemia with nonobstructive coronary artery disease (AINOCA) is often observed in females. Coronary microvascular dysfunction (CMD) and coronary epicardial spasm (CES) are the principal cause of AINOCA. The clinical outcomes of Western patients with CMD were less satisfactory than expected, while the prognosis of Japanese patients with CES treated with medications including calcium channel blockers was favorable. However, the incidence and clinical features of coronary spasm endotypes were different between Western and Japanese populations. Furthermore, sex-related differences in the clinical manifestations and outcomes of patients with different spasm endotypes remain uncertain beyond race. In this article, we will review the sex differences in Japanese AINOCA patients with coronary vasomotor disorders, including CMD and CES, and compare them with those of Western patients.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama City, Ehime Prefecture, Japan.
| | - Tomoki Sakaue
- Department of Cardiology, Yawatahama City General Hospital, Yawatahama City, Ehime Prefecture, Japan
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Clinical Outcomes and Provoked Epicardial Spasm Phenotypes via Intracoronary Acetylcholine Testing in 680 Patients with Angina and Nonobstructive Coronary Arteries. Life (Basel) 2022; 12:life12101465. [PMID: 36294900 PMCID: PMC9605297 DOI: 10.3390/life12101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/05/2022] [Accepted: 09/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Epicardial spasm (ES) phenotypes may be related to the prognosis in patients with coronary spastic angina. Objectives: The purpose of this study was to elucidate the relationship between angiographic coronary vasomotor responses to intracoronary acetylcholine (ACh) injection and prognosis in patients with angina and nonobstructive coronary artery disease (ANOCAD). Methods: This was a retrospective, observational, single-center study of 680 patients with ANOCAD. ACh spasm provocation tests on both coronary arteries were performed without administering nitroglycerine to relieve provoked spasm in a first-attempt artery. ACh was injected in incremental doses of 20/50/100/200 μg into the left coronary artery and 20/50/80 μg into the right coronary artery. Positive ES was defined as ≥90% stenosis and usual chest pain and ischemic ECG changes. Results: Provoked positive ES was observed in 310 patients (46%), including 85 patients (13%) with focal spasm, 150 patients (22%) with diffuse spasm, and 75 patients (11%) with combined spasm (diffuse spasm and focal spasm), whereas the remaining 370 patients (54%) had no provoked spasm. An unclassified ACh test was observed in 186 patients (27%), while 184 patients (27%) had a complete negative ACh test. The clinical outcomes in patients with complete negative ES were satisfactory compared with those with positive ES and unclassified ACh test results. The prognosis in patients with an unclassified ACh test was not different from those with a positive ES. Furthermore, prognosis in patients with ES phenotypes was not different among the three groups. Conclusions: There was no correlation between provoked ES phenotypes via intracoronary ACh testing and prognosis in patients with ANOCAD; however, clinical outcomes in patients with positive ES and unclassified ACh tests were worse compared to those with complete negative ACh tests. We should focus on the treatments in patients with unclassified ACh tests as well as those with ESs.
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Feenstra RG, Seitz A, Boerhout CK, Bukkems LH, Stegehuis VE, Teeuwisse PJ, de Winter RJ, Sechtem U, Piek JJ, van de Hoef TP, Ong P, Beijk MA. Principles and pitfalls in coronary vasomotor function testing. EUROINTERVENTION 2022; 17:1271-1280. [PMID: 34278990 PMCID: PMC9725006 DOI: 10.4244/eij-d-21-00402] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Coronary vasomotor dysfunction can be diagnosed in a large proportion of patients with angina in the presence of non-obstructive coronary artery disease (ANOCA) using comprehensive protocols for coronary vasomotor function testing (CFT). Although consensus on diagnostic criteria for endotypes of coronary vasomotor dysfunction has been published, consensus on a standardised study testing protocol is lacking. AIMS In this review we provide an overview of the variations in CFT used and discuss the practical principles and pitfalls of CFT. METHODS For the purposes of this review, we assessed study protocols that evaluate coronary vasomotor response as reported in the literature. We compared these protocols regarding a number of procedural aspects and chose six examples to highlight the differences and uniqueness. RESULTS Currently, numerous protocols co-exist and vary in vascular domains tested, the manner in which to test these domains (e.g., preprocedural discontinuation of medication, provocative agent, solution, infusion time, and target artery) and techniques used for measurements (e.g., Doppler vs thermodilution technique). CONCLUSIONS This lack of consensus on a uniform functional testing protocol hampers both a broader clinical acceptance of the concepts of coronary vasomotor dysfunction, and the widespread adoption of such testing protocols in current clinical practice. Furthermore, the endotype of coronary vasomotor dysfunction might differ among the few specialised centres that perform CFT as a result of the use of different protocols.
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Affiliation(s)
- Rutger G.T. Feenstra
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Andreas Seitz
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Coen K.M. Boerhout
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Laura H. Bukkems
- Department of Clinical Pharmacy, Amsterdam UMC, Amsterdam, the Netherlands
| | - Valérie E. Stegehuis
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | | | - Robbert J. de Winter
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Jan J. Piek
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Tim P. van de Hoef
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Marcel A.M. Beijk
- AMC Heartcenter, Room B2-250, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
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Sueda S, Sakaue T. Intracoronary ergonovine testing among 505 consecutive Japanese patients with angina-like chest pain and unobstructed coronary artery disease. Heart Vessels 2022; 37:931-941. [DOI: 10.1007/s00380-021-02002-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/26/2021] [Indexed: 01/20/2023]
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Role of acetylcholine spasm provocation test as a pathophysiological assessment in nonobstructive coronary artery disease. Cardiovasc Interv Ther 2020; 36:39-51. [PMID: 33108592 PMCID: PMC7829227 DOI: 10.1007/s12928-020-00720-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 12/21/2022]
Abstract
Coronary angiography (CAG) sometimes shows nonobstructive coronary arteries in patients with suspected angina or acute coronary syndrome (ACS). The high prevalence of nonobstructive coronary artery disease (CAD) in those patients has recently been reported not only in Japan but also in Western countries, and is clinically attracting attention. Coronary spasm is considered to be one of the leading causes of both suspected stable angina and ACS with nonobstructive coronary arteries. Coronary spasm could also be associated with left ventricular dysfunction leading to heart failure, which could be improved following the administration of calcium channel blockers. Because we rarely capture spontaneous attacks of coronary spasm with electrocardiograms or Holter recordings, an invasive diagnostic modality, acetylcholine (ACh) provocation test, can be useful in detecting coronary spasm during CAG. Furthermore, we can use the ACh-provocation test to identify high-risk patients with coronary spasm complicated with organic coronary stenosis, and then treat with intensive care. Nonobstructive CAD includes not only epicardial coronary spasm but also microvascular spasm or dysfunction that can be associated with recurrent anginal attacks and poor quality of life. ACh-provocation test could also be helpful for the assessment of microvascular spasm or dysfunction. We hope that cardiologists will increasingly perform ACh-provocation test to assess the pathophysiology of nonobstructive CAD.
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Vasospastic angina and overlapping cardiac disorders in patients resuscitated from cardiac arrest. Heart Vessels 2020; 36:321-329. [PMID: 32990791 DOI: 10.1007/s00380-020-01705-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Vasospastic angina (VSA) reportedly accounts for one form of sudden cardiac arrest (SCA). Intracoronary acetylcholine (ACh) testing is useful for diagnosing VSA although invasive provocation testing after SCA is a clinical challenge. In addition, even if the ACh test is positive, any causal relationship between VSA and SCA is often unclear because patients with VSA may have other underlying cardiac disorders. METHODS A total of 20 patients without overt structural heart disease who had been fully resuscitated from SCA were included. All patients underwent the ACh provocation test and scrutiny such as cardiac computed tomography or magnetic resonance imaging. Patients were followed up for all-cause death or recurrent SCA including appropriate implantable cardioverter defibrillator therapy. RESULTS An ACh provocation test was performed 20 ± 17 days after cardiac arrest. Fifteen out of 20 (75.0%) patients had a positive ACh test and 2 (10.0%) had adverse events such as ventricular tachycardia and transient cardiogenic shock during the test. In patients with a positive ACh test, 6 of 15 (40.0%) patients had other overlapping cardiac disorders such as long QT syndrome, Brugada syndrome, cardiac sarcoidosis, myocarditis, or cardiomyopathy. Long-term prognosis was not different regardless of a positive ACh test or the presence of other cardiac disorders overlapping with VSA. CONCLUSIONS Three-quarters of the patients who had been resuscitated from SCA had a positive ACh test. Further examinations revealed other overlapping cardiac disorders in addition to VSA in 40% of patients with a positive ACh test.
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Questionnaire in patients with aborted sudden cardiac death due to coronary spasm in Japan. Heart Vessels 2020; 35:1640-1649. [PMID: 32533313 DOI: 10.1007/s00380-020-01644-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/05/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVES We investigated the medical or mechanical therapy, and the present knowledge of Japanese cardiologists about aborted sudden cardiac death (ASCD) due to coronary spasm. METHODS A questionnaire was developed regarding the number of cases of ASCD, implantable cardioverter-defibrillator (ICD), and medical therapy in ASCD patients due to coronary spasm. The questionnaire was sent to the Japanese general institutions at random in 204 cardiology hospitals. RESULTS The completed surveys were returned from 34 hospitals, giving a response rate of 16.7%. All SCD during the 5 years was observed in 5726 patients. SCD possibly due to coronary spasm was found in 808 patients (14.0%) and ASCD due to coronary spasm was observed in 169 patients (20.9%). In 169 patients with ASCD due to coronary spasm, one or two coronary vasodilators was administered in two-thirds of patients [113 patients (66.9%)], while more than 3 coronary vasodilators were found in 56 patients (33.1%). ICD was implanted in 117 patients with ASCD due to coronary spasm among these periods including 35 cases with subcutaneous ICD. Majority of cause of ASCD was ventricular fibrillation, whereas pulseless electrical activity was observed in 18 patients and complete atrioventricular block was recognized in 7 patients. Mean coronary vasodilator number in ASCD patients with ICD was significantly lower than that in those without ICD (2.1 ± 0.9 vs. 2.6 ± 1.0, p < 0.001). Although 16 institutions thought that the spasm provocation tests under the medications had some clinical usefulness of suppressing the next fatal arrhythmias, spasm provocation tests under the medication were performed in just 4 institutions. CONCLUSIONS In the real world, there was no fundamental strategy for patients with ASCD due to coronary spasm. Each institution has each strategy for these patients. Cardiologists should have the same strategy and the same knowledge about ASCD patients due to coronary spasm in the future.
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Sueda S, Kohno H. Spontaneous coronary artery spasm detected by computed tomography coronary angiography: Provoked spasm site similar to intracoronary injection of ergonovine but not acetylcholine. J Cardiol Cases 2019; 20:209-212. [PMID: 31762835 DOI: 10.1016/j.jccase.2019.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/05/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022] Open
Abstract
A 61-year-old man was admitted to our hospital due to chest pain on both rest and effort. After the computed tomography coronary angiography, coronary stenosis was recognized at segment 3. Because inferior ischemia on stress myocardial perfusion scintigraphy with 201 thallium chloride induced by adenosine was found, we planned to perform the coronary intervention. After control coronary angiography, no significant stenosis was found in the right coronary artery. Intracoronary acetylcholine testing disclosed diffuse spasm at segment 4, whereas intracoronary ergonovine administration documented the total spasm at segment 3. After the intracoronary administration of nitrate, we diagnosed him with coronary spastic angina without organic stenosis. <Learning objective: We describe a case of coronary spastic angina whose spontaneous coronary spasm was detected by computed tomography coronary angiography incidentally.>.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Ehime, Japan
| | - Hiroaki Kohno
- Department of Cardiology, Tsukazaki Hospital, Himeji, Japan
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Clinical characteristics in patients with rest angina and hypoplastic right coronary artery. Heart Vessels 2019; 35:443-450. [PMID: 31529177 DOI: 10.1007/s00380-019-01507-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022]
Abstract
Hypoplastic coronary artery disease is a rare congenital abnormality reported to be associated with myocardial infarction and sudden cardiac death. Provoked positive spasm in the left circumflex coronary artery (LCX) with pharmacological spasm provocation tests was remarkably lower than other coronary arteries. We sometimes encountered patients with rest angina and hypoplastic right coronary artery (H-RCA). Among 5953 patients with diagnostic and follow-up coronary arteriography, we found 93 patients (1.6%) with H-RCA. During the same period, we could perform spasm provocation tests in 564 patients with rest angina including 13 patients with H-RCA and 249 patients with effort angina including 10 patients with H-RCA. Pharmacological spasm provocation tests were performed in 51 of 93 patients including 34 patients with ischemic heart disease (IHD) and 17 patients with non-IHD. Provoked spasm incidence in patients with IHD was higher than in those with non-IHD but not significant (52.9% vs. 29.4%, p = 0.1114). Provoked positive spasm in the LCX in patients with rest angina and H-RCA was significantly higher than that in those without H-RCA (69.2% vs. 23.4%, p < 0.001). Provoked spasm on both left anterior descending artery and LCX in patients with rest angina and H-RCA was also remarkably higher than in those without H-RCA (53.8% vs. 3.1%, p < 0,001). There were no clinical differences between patients with and without H-RCA rest angina. Two-vessel spasm (61.5% vs. 0%, p < 0.01) and LCX-provoked spasm (69.2% vs. o%, p < 0.01) were significantly higher in patients with H-RCA and rest angina than that in those with H-RCA and effort angina. In patients with rest angina and H-RCA, LCX-positive spasm was significantly higher and these patients may have a potential of high disease activity in the clinic as a coronary spastic angina.
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