Papaverine-induced chest pain due to coronary vascular steal: demonstration with angiographic and intracoronary flow velocity measurements

ST elevation after intracoronary administration of Papaverine for fractional flow reserve estimation

INTRODUCTION

Intracoronary (IC) papaverine which is one of the commonly used agents for Fractional Flow Reserve (FFR) estimation has been reported to cause transient ST elevation in some patients. This phenomenon has not been systematically studied.

MATERIAL AND METHODS

This is a prospective, observational study. Consecutive patients, who underwent FFR at our institute using IC papaverine from May 2012 to April 2013, were included. FFR was done when clinically indicated. The procedure involved administration of 20 mg papaverine (Paparin)--Troikaa, Ahmedabad) as a fast bolus by intracoronary route followed by a 10 cc contrast flush, following which pressure measurements were made. Continuous ECG recording by Philips Hemodynamic Laboratory was obtained for all patients throughout the procedure. Post procedure, they were observed for any delayed effects and eventual outcome was documented. Fischer's mid-p test was used for statistical analysis.

RESULT

Twenty-five patients (18 males, 7 females, mean age 57.9 ± 20 years) underwent FFR using Papaverine. The mean LVEF was (51 ± 15%). Fourteen patients (56%) developed transient ST elevation ≥0.5 mm in one or more leads which resolved spontaneously in all cases without any sequelae. The presence of a significant lesion either in the coronary artery being evaluated or in a remote coronary artery did not predict the ST elevation. 70.5% of diabetics (p = 0.02), 75% of hypertensives (p = 0.008) and 75% of patients with LVH (p = 0.008) had ST elevation. None of the 5 patients without any one of these comorbidities showed ST elevation.

CONCLUSION

Transient ST elevation occurs in a significant proportion of cases receiving IC papaverine which is not associated with any adverse clinical outcomes. Micro vascular dysfunction is the most likely mechanism of this phenomenon.

Changes in glutathione and cellular energy as potential mechanisms of papaverine-induced hepatotoxicity in vitro

The purpose of this study was to elucidate the mechanism of hepatotoxicity of papaverine hydrochloride (papaver) in vitro. To evaluate the role of metabolism in the toxicity of papaver, cells were pretreated with SKF-525A or benzyl imidazole (cytochrome P450 system inhibitors) for 24 hr at 1 x 10(-5) or 1 x 10(-4) M, respectively, or with phenobarbital sodium (cytochrome P450 system inducer) for 3 days at 2 x 10(-3) M. Cells then were exposed to concentrations of papaver ranging from 1 x 10(-5) to 1 x 10(-3) M for 4 to 24 hr. Cytotoxicity was evaluated by enzyme leakage (lactate dehydrogenase) and by energy status of the cells (ATP/ADP). The role of biological reactive intermediates in the toxicity of papaver was investigated by measuring changes in cellular reduced glutathione levels (GSH), by inhibiting GSH synthesis, and by determining the production of lipid peroxidation (LPX). Papaverine produced concentration- and time-dependent increases in enzyme leakage, with significant effects occurring by the 8-hr exposure period. Pretreatment with SKF-525A or benzyl imidazole increased enzyme leakage induced by papaver especially at a later time frame (24 hr), but pretreatment with phenobarbital delayed the onset of cytotoxicity from 8 to 12 hr. Decreases in GSH levels paralleled the time course of enzyme leakage. However, the administration of buthionine sulfoximine to cell cultures dramatically decreased the time by which papaver induced cellular injury (2 hr vs 8 hr). Changes in cellular energy status (ATP/ADP) were also detected earlier than enzyme leakage (4 hr vs 8 hr). In contrast, no significant production of lipid peroxidation was noted in papaver-treated cultures. We suggest that the mechanism of papaver-induced hepatotoxicity may be related to alterations in glutathione balance of the cells and to disruption of energy homeostasis.