Variations in presentation and various options in management of variant angina

The Role of Vasospasm and Microcirculatory Dysfunction in Fluoropyrimidine-Induced Ischemic Heart Disease

Cardiovascular diseases and cancer are the leading cause of morbidity and mortality globally. Cardiotoxicity from chemotherapeutic agents results in substantial morbidity and mortality in cancer survivors and patients with active cancer. Cardiotoxicity induced by 5-fluorouracil (5-FU) has been well established, yet its incidence, mechanisms, and manifestation remain poorly defined. Ischemia secondary to coronary artery vasospasm is thought to be the most frequent cardiotoxic effect of 5-FU. The available evidence of 5-FU-induced epicardial coronary artery spasm and coronary microvascular dysfunction suggests that endothelial dysfunction or primary vascular smooth muscle dysfunction (an endothelial-independent mechanism) are the possible contributing factors to this form of cardiotoxicity. In patients with 5-FU-related coronary artery vasospasm, termination of chemotherapy and administration of nitrates or calcium channel blockers may improve ischemic symptoms. However, there are variable results after administration of nitrates or calcium channel blockers in patients treated with 5-FU presumed to have myocardial ischemia, suggesting mechanisms other than impaired vasodilatory response. Clinicians should investigate whether chest pain and ECG changes can reasonably be attributed to 5-FU-induced cardiotoxicity. More prospective data and clinical randomized trials are required to understand and mitigate potentially adverse outcomes from 5-FU-induced cardiotoxicity.

Coronary vasospasm as an etiology of recurrent ventricular fibrillation in the absence of coronary artery disease: a case report

Background: Vasospastic angina (VA), or Prinzmetal’s angina, is characterized by symptoms of coronary angina caused by coronary vasospasm, usually in the absence of atherosclerotic changes. It typically presents with chest pain, which can be accompanied by transient electrocardiographic changes, if visualized during the attack. It can also rarely present with severe manifestations of acute myocardial angina, ventricular fibrillation, or cardiac arrest.

Case presentation: We present a case of a 50-year-old Caucasian male who initially presented to the hospital with chest pain and was diagnosed with VA. Later, he was brought to the hospital by emergency medical services later with ventricular fibrillation, despite normal coronary anatomy on angiogram. He was managed with placement of an intra–cardiac defibrillator (ICD) for secondary prevention. The patient continued to have recurrent episodes of ventricular fibrillation with associated ICD shocks, and had multiple admissions to the hospital with similar presentations. Symptoms and arrhythmia improved after optimizing antianginal therapy.

Conclusions: Ventricular fibrillation can be an uncommon but severe manifestation during VA crises. In cases with normal coronary vasculature, it is important to recognize VA as a cause of recurrent ventricular fibrillation in order to optimize medical management for prevention of fatal arrhythmias.

The role of computed tomography coronary angiography in multi-vessel coronary vasospasm: a case report

Background

Coronary vasospasm can present like an acute coronary syndrome (ACS) with an intense vasoconstriction resulting in total or near-total occlusion of one or more of the coronary vessels. Definitive diagnosis can be made by intracoronary provocation testing.

Case summary

A 37-year-old Caucasian male and smoker was admitted with chest pain. Highly sensitive troponin-I was positive at 63 ng/L (99th percentile upper reference limit, <15 ng/L) with a repeat value of 45 ng/L three and a half hours later which was of clinical significance. Serial electrocardiography (ECG) showed no ischaemic changes. Coronary angiography revealed several distal and side branch stenoses; however, angiographic appearances were atypical of coronary plaque. A differential diagnosis of spontaneous coronary artery dissection was suspected although the patient was pain free during the procedure. Computed tomography coronary angiography (CTCA) demonstrated normal coronary arteries, confirmed on repeat invasive coronary angiography. Cold pressor testing was unsuccessful in reproducing vasospasm. Acute coronary syndrome treatment was discontinued, he received smoking cessation advice and Amlodipine 5 mg daily was started. He has experienced no further episodes of cardiac chest pain on follow-up consultation 7 months later.

Discussion

This is an unusual case of persistent, extensive coronary vasospasm in a patient without ongoing chest pain or ischaemic ECG changes. Intracoronary nitrates are usually effective at relieving coronary spasm. Cold pressor testing has poor sensitivity for diagnosing vasospasm when compared to intracoronary provocation testing using either acetylcholine or ergonovine. Multi-slice CTCA may help to discriminate coronary plaque from coronary vasospasm when there is diagnostic uncertainty.

Coronary Vasospasm After Burn Injury: First Described Case Series of a Lethal Lesion

Burn injuries generate multisystem physiological derangements. The authors present a case series of three patients developing acute coronary syndrome (ACS) stemming from coronary vasospasm (CVS) over a course of 5 months. This etiology of ACS is significant as it has previously not been described in burn patients and requires a different management algorithm than vaso-occlusive disease.All patients were admitted to a single accredited burn unit. Burn mechanisms were flash burn, chemical fire, and house fire. TBSA were 20%, 72%, and 31%, respectively. Ages were 67-, 41-, and 52-year-old men. All smoked tobacco, and one had diabetes and coronary artery disease. CVS presented with acute onset ST elevations, severe bradycardia, and cardiac arrest in all. Diagnosis was made via EKG and angiography. Treatment was undertaken with nitrates and calcium channel blockers. One of the patients died of refractory disease.The authors identified CVS in burn patients with an incidence of 2% of admissions and accounting for 17% of our burn mortality during this period. To date, there is no linkage between CVS and burns described in humans; however, there is a well-described animal model in rats. The risk factors for CVS are common among burn patients, particularly smoking and endothelial dysfunction. CVS may be a significant cause of ACS in burn patients, and it should be considered in the setting of ACS especially with a negative angiography. Knowledge of this disease state can change burn management to mitigate risk and accommodate specific cardiac treatments.

Pharmacotherapy of Vasospastic Angina

Vasospastic angina is a diagnosis of exclusion that manifests with signs and symptoms, which overlap with obstructive coronary artery disease, most often ST-segment elevation myocardial infarction. The pharmacotherapy that is available to treat vasospastic angina can help ameliorate angina symptoms. However, the etiology of vasospastic angina is ill-defined, making targeted pharmacotherapy difficult. Most patients receive pharmacotherapy that includes calcium channel blockers and/or long-acting nitrates. This article reviews the efficacy and safety of the pharmacotherapy used to treat vasospastic angina. High-dose calcium channel blockers possess the most evidence, with respect to decreasing angina incidence, frequency, and duration. However, not all patients respond to calcium channel blockers. Nitrates and/or alpha1-adrenergic receptor antagonists can be used in patients who respond poorly to calcium channel blockers. Albeit, evidence for use of nitrates and alpha1-adrenergic receptor antagonists in vasospastic angina is not as robust as calcium channel blockers and can exacerbate adverse effects when added to calcium channel blocker therapy. Despite having a clear benefit in patients with obstructive coronary artery disease, the benefit of beta-adrenergic receptor antagonists, statins, and aspirin remains unclear. More data are needed to elucidate whether or not these agents are beneficial or harmful to patients being treated for vasospastic angina. Overall, the use of pharmacotherapy for the treatment of vasospastic angina should be guided by patient-specific factors, such as tolerability, adverse effects, drug–drug, and drug–disease interactions.

Coronary artery spasm: An often overlooked diagnosis

Coronary vasospasm can lead to myocardial injury and even sudden cardiac death. It has generally been overlooked as a diagnosis since atherosclerosis is a more common cause of acute coronary syndromes and because of the dilemma involved in its diagnosis. A middle-aged man with a history of smoking and cocaine use presented to the emergency department with left-sided arm/chest discomfort and diaphoresis. The electrocardiogram showed anterior ST elevation and hyper-acute T waves, which completely resolved shortly after sublingual nitroglycerin was administered. Subsequent angiogram revealed a 70% focal stenosis in the mid-left anterior descending artery. Coronary vasospasm occurs more commonly in arteries with underlying atheromatous disease, although normal vessels are not excluded. Cigarette smoking and cocaine use are among the major culprits that have been implicated as risk factors for the occurrence of coronary vasospasm. Eventually, the patient had percutaneous coronary intervention of his left-anterior descending artery and remained asymptomatic.

Presentation, management, and outcomes of ischaemic heart disease in women

Scientific interest in ischaemic heart disease (IHD) in women has grown considerably over the past 2 decades. A substantial amount of the literature on this subject is centred on sex differences in clinical aspects of IHD. Many reports have documented sex-related differences in presentation, risk profiles, and outcomes among patients with IHD, particularly acute myocardial infarction. Such differences have often been attributed to inequalities between men and women in the referral and treatment of IHD, but data are insufficient to support this assessment. The determinants of sex differences in presentation are unclear, and few clues are available as to why young, premenopausal women paradoxically have a greater incidence of adverse outcomes after acute myocardial infarction than men, despite having less-severe coronary artery disease. Although differential treatment on the basis of patient sex continues to be described, the extent to which such inequalities persist and whether they reflect true disparity is unclear. Additionally, much uncertainty surrounds possible sex-related differences in response to cardiovascular therapies, partly because of a persistent lack of female-specific data from cardiovascular clinical trials. In this Review, we assess the evidence for sex-related differences in the clinical presentation, treatment, and outcome of IHD, and identify gaps in the literature that need to be addressed in future research efforts.

Coronary vasospasm: is it a myth?

This review addresses some myths about coronary vasospasm as the cause of angina pectoris. Coronary artery vasospasm is a common phenomenon, which is clinically encountered by busy cardiologists almost on a daily basis. It is the cause of resting angina in many patients without significant coronary artery disease, but also in patients with atherosclerotic coronary artery disease but no subtotal lesion. Although coronary artery vasospasm can be suspected clinically, proof cannot usually be obtained by non-invasive means but is easily available during cardiac catheterization. Patients with vasospastic angina are repeatedly exposed to this invasive procedure as most cardiologists suspect a coronary lesion requiring intervention as the cause of the patient's resting angina. Adding an intracoronary acetylcholine test to the catheterization procedure may establish the correct diagnosis and enable treatment with calcium antagonists and nitrates. Epicardial vasospasm may be observed during the test in patients with and without angiographically visible lesions in the coronary arteries. Almost 50% of all pathological tests, however, do not show epicardial vasospasm but reproduction of symptoms and electrocardiogram signs of ischemia indicating spasm of the microvessels.

Depression with panic episodes and coronary vasospasm

Variant (Prinzmetal's) angina is an uncommon cause of precordial pain caused by coronary vasospasm and characterized by transient ST elevation and negative markers of myocardial necrosis. This is the case of a female patient with a prior history of depression and panic attacks who presented with recurrent symptoms including chest pain. A cardiac event monitor positively documented coronary vasospasm associated with anxiety-provoking chest pain, whereas the coronary arteries were angiographically normal. We noted that the frequency of angina attacks apparently increased during the period that coincided with the introduction of Bupropion SR for treatment of the patient's depression. Considering the possibility of bupropion-associated negative impact on coronary vasospasm, the antidepressant therapy was adjusted to exclude this drug. Although Prinzmetal's angina is relatively uncommon, we suspect that a routine use of cardiac event monitors in subjects with panic disorder might reveal a greater incidence of coronary vasospasm in this patient population.

Anomalous left coronary artery from aorta with Prinzmetal's angina: a postoperative dilemma successfully managed

Anomalous aortic origin of one of the coronary arteries is uncommon. There have been few reports of the left coronary artery arising from the noncoronary sinus. The occurrence of Prinzmetal's angina in association with anomalous aortic origin is extremely rare. We report a case of such a combination and discuss the diagnostic options and therapeutic decision making.

Myocardial infarction with normal coronary arteries: a conundrum with multiple aetiologies and variable prognosis: an update

The existence of myocardial infarction despite angiographically normal coronary arteries was recognized more than 30 years ago. Since then, various series of such patients have been described, but the aetiology and pathogenesis of the condition are still a source of debate. Evidence exists for a role of coronary vasospasm, thrombosis, embolization and inflammation, per se or combined, in determining the occurrence of myocardial infarction in the presence of angiographically normal coronary arteries. Endothelial dysfunction, possibly superimposed to nonangiographically evident atherosclerosis, may be an underlying common feature predisposing to the acute event. Additionally, myocarditis may explain some of these occurrences. Myocardial infarction with normal coronary arteries is therefore likely the result of multiple pathogenetic mechanisms. Although most reports emphasize the good prognosis of this condition, in general much better than myocardial infarction with coronary artery disease, prognosis is likely variable according to the underlying mechanism. This review summarizes current knowledge on this condition and examines areas of recent progress.