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Rehan R, Wong CC, Weaver J, Jain P, Adams M, Tremmel JA, Ng MK, Yong AS. Usefulness of temporary pacemaker during acetylcholine provocation testing. IJC HEART & VASCULATURE 2024; 53:101440. [PMID: 38966805 PMCID: PMC11222927 DOI: 10.1016/j.ijcha.2024.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 05/31/2024] [Accepted: 06/02/2024] [Indexed: 07/06/2024]
Affiliation(s)
- Rajan Rehan
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Australia
- Department of Cardiology, Concord Hospital, University of Sydney, Australia
- Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | | | - James Weaver
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Australia
- Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Pankaj Jain
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Australia
- Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Mark Adams
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Australia
- Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | | | - Martin K.C. Ng
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Australia
- Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Andy S.C. Yong
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Australia
- Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
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Woudstra J, Feenstra RGT, Vink CEM, Marques KMJ, Boerhout CKM, de Jong EAM, de Waard GA, van de Hoef TP, Chamuleau SAJ, Eringa EC, Piek JJ, Appelman Y, Beijk MAM. Comparison of the Diagnostic Yield of Intracoronary Acetylcholine Infusion and Acetylcholine Bolus Injection Protocols During Invasive Coronary Function Testing. Am J Cardiol 2024; 217:49-58. [PMID: 38417650 DOI: 10.1016/j.amjcard.2024.01.038] [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: 12/22/2023] [Revised: 01/09/2024] [Accepted: 01/19/2024] [Indexed: 03/01/2024]
Abstract
Coronary endothelial dysfunction (CED) and coronary artery spasm (CAS) are causes of angina with no obstructive coronary arteries in patients. Both can be diagnosed by invasive coronary function testing (ICFT) using acetylcholine (ACh). This study aimed to evaluate the diagnostic yield of a 3-minute ACh infusion as compared with a 1-minute ACh bolus injection protocol in testing CED and CAS. We evaluated 220 consecutive patients with angina and no obstructive coronary arteries who underwent ICFT using continuous Doppler flow measurements. Per protocol, 110 patients were tested using 3-minute infusion, and thereafter 110 patients using 1-minute bolus injections, because of a protocol change. CED was defined as a <50% increase in coronary blood flow or any epicardial vasoconstriction in reaction to low-dose ACh and CAS according to the Coronary Vasomotor Disorders International Study Group (COVADIS) criteria, both with and without T-wave abnormalities, in reaction to high dose ACh. The prevalence of CED was equal in both protocols (78% vs 79%, p = 0.869). Regarding the endotypes of CAS according to COVADIS, the equivocal endotype was diagnosed less often in the 3 vs 1-minute protocol (24% vs 44%, p = 0.004). Including T-wave abnormalities in the COVADIS criteria resulted in a similar diagnostic yield of both protocols. Hemodynamic changes from baseline to the low or high ACh doses were comparable between the protocols for each endotype. In conclusion, ICFT using 3-minute infusion or 1-minute bolus injections of ACh showed a similar diagnostic yield of CED. When using the COVADIS criteria, a difference in the equivocal diagnosis was observed. Including T-wave abnormalities as a diagnostic criterion reclassified equivocal test results into CAS and decreased this difference. For clinical practice, we recommend the inclusion of T-wave abnormalities as a diagnostic criterion for CAS and the 1-minute bolus protocol for practicality.
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Affiliation(s)
- Janneke Woudstra
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands.
| | - Rutger G T Feenstra
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Caitlin E M Vink
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Koen M J Marques
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Coen K M Boerhout
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Elize A M de Jong
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands; Department of Cardiology, University Medical Center Utrecht, The Netherlands
| | - Guus A de Waard
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, University Medical Center Utrecht, The Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Etto C Eringa
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, The Netherlands; Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
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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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Rehan R, Beltrame J, Yong A. Insights into the invasive diagnostic challenges of coronary artery vasospasm - A systematic review. J Cardiol 2024; 83:8-16. [PMID: 37541429 DOI: 10.1016/j.jjcc.2023.07.020] [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: 05/11/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/06/2023]
Abstract
Coronary provocation testing is an essential diagnostic procedure when evaluating vasospastic angina. Invasive methods using acetylcholine or ergonovine are considered the current gold standard. Despite efforts from global cardiovascular institutions, current protocols vary in dosage, administration time, and procedural approach. In addition, concerns over the specificity of findings and potential complications have limited routine uptake of this procedure in clinical practice. This systematic review evaluates current diagnostic protocols, focusing on invasive provocation testing. We included studies using intracoronary provocation testing with acetylcholine or ergonovine for the assessment of coronary artery vasospasm that detailed specific elements of the procedure (dosage, administration time, etc.) and included ≥50 patients. A total of 28 articles met strict inclusion criteria. Our review highlights the heterogeneity between current diagnostic protocols for invasive provocation testing. We believe standardization of a diagnostic protocol will encourage both current and future cardiologists to incorporate such procedures in the evaluation of variant angina.
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Affiliation(s)
- Rajan Rehan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Department of Cardiology, Concord Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - John Beltrame
- Discipline of Medicine, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, Adelaide, South Australia, Australia
| | - Andy Yong
- Department of Cardiology, Concord Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
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Hung MJ, Yeh CT, Kounis NG, Koniari I, Hu P, Hung MY. Coronary Artery Spasm-Related Heart Failure Syndrome: Literature Review. Int J Mol Sci 2023; 24:ijms24087530. [PMID: 37108691 PMCID: PMC10145866 DOI: 10.3390/ijms24087530] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Although heart failure (HF) is a clinical syndrome that becomes worse over time, certain cases can be reversed with appropriate treatments. While coronary artery spasm (CAS) is still underappreciated and may be misdiagnosed, ischemia due to coronary artery disease and CAS is becoming the single most frequent cause of HF worldwide. CAS could lead to syncope, HF, arrhythmias, and myocardial ischemic syndromes such as asymptomatic ischemia, rest and/or effort angina, myocardial infarction, and sudden death. Albeit the clinical significance of asymptomatic CAS has been undervalued, affected individuals compared with those with classic Heberden's angina pectoris are at higher risk of syncope, life-threatening arrhythmias, and sudden death. As a result, a prompt diagnosis implements appropriate treatment strategies, which have significant life-changing consequences to prevent CAS-related complications, such as HF. Although an accurate diagnosis depends mainly on coronary angiography and provocative testing, clinical characteristics may help decision-making. Because the majority of CAS-related HF (CASHF) patients present with less severe phenotypes than overt HF, it underscores the importance of understanding risk factors correlated with CAS to prevent the future burden of HF. This narrative literature review summarises and discusses separately the epidemiology, clinical features, pathophysiology, and management of patients with CASHF.
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Affiliation(s)
- Ming-Jui Hung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Keelung, Chang Gung University College of Medicine, Keelung City 24201, Taiwan
| | - Chi-Tai Yeh
- Department of Medical Research and Education, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Continuing Education Program of Food Biotechnology Applications, College of Science and Engineering, National Taitung University, Taitung 95092, Taiwan
| | - Nicholas G Kounis
- Department of Cardiology, University of Patras Medical School, 26221 Patras, Greece
| | - Ioanna Koniari
- Cardiology Department, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Patrick Hu
- Department of Internal Medicine, School of Medicine, University of California, Riverside, Riverside, CA 92521, USA
- Department of Cardiology, Riverside Medical Clinic, Riverside, CA 92506, USA
| | - Ming-Yow Hung
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, No.291, Zhongzheng Rd., Zhonghe District, New Taipei City 23561, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei City 110301, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City 23561, Taiwan
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Perera D, Berry C, Hoole SP, Sinha A, Rahman H, Morris PD, Kharbanda RK, Petraco R, Channon K. Invasive coronary physiology in patients with angina and non-obstructive coronary artery disease: a consensus document from the coronary microvascular dysfunction workstream of the British Heart Foundation/National Institute for Health Research Partnership. Heart 2022; 109:88-95. [PMID: 35318254 PMCID: PMC9811089 DOI: 10.1136/heartjnl-2021-320718] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/17/2022] [Indexed: 02/04/2023] Open
Abstract
Nearly half of all patients with angina have non-obstructive coronary artery disease (ANOCA); this is an umbrella term comprising heterogeneous vascular disorders, each with disparate pathophysiology and prognosis. Approximately two-thirds of patients with ANOCA have coronary microvascular disease (CMD). CMD can be secondary to architectural changes within the microcirculation or secondary to vasomotor dysfunction. An inability of the coronary vasculature to augment blood flow in response to heightened myocardial demand is defined as an impaired coronary flow reserve (CFR), which can be measured non-invasively, using imaging, or invasively during cardiac catheterisation. Impaired CFR is associated with myocardial ischaemia and adverse cardiovascular outcomes.The CMD workstream is part of the cardiovascular partnership between the British Heart Foundation and The National Institute for Health Research in the UK and comprises specialist cardiac centres with expertise in coronary physiology assessment. This document outlines the two main modalities (thermodilution and Doppler techniques) for estimation of coronary flow, vasomotor testing using acetylcholine, and outlines a standard operating procedure that could be considered for adoption by national networks. Accurate and timely disease characterisation of patients with ANOCA will enable clinicians to tailor therapy according to their patients' coronary physiology. This has been shown to improve patients' quality of life and may lead to improved cardiovascular outcomes in the long term.
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Affiliation(s)
- Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Colin Berry
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Cardiology, Golden Jubilee National Hospital, Clydebank, UK
| | | | - Aish Sinha
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Haseeb Rahman
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Paul D Morris
- Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | | | - Ricardo Petraco
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Keith Channon
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
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Sinha A, Rahman H, Perera D. Vasospastic Angina: A Contemporary Review of its Pathophysiology, Diagnosis and Management. Heart Int 2022; 16:99-104. [PMID: 36741101 PMCID: PMC9872780 DOI: 10.17925/hi.2022.16.2.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/30/2022] [Indexed: 12/25/2022] Open
Abstract
Nearly 40% of patients presenting to the catheter laboratory with angina have non-obstructed coronary arteries (ANOCA), an umbrella term that encompasses distinct pathophysiological entities, such as coronary artery spasm. Coronary artery spasm leads to sudden reversible coronary flow attenuation, which clinically manifests as vasospastic angina (VSA). VSA is associated with poor quality of life and an increased risk of major adverse cardiac events. However, the pathophysiological mechanisms underlying this phenomenon are incompletely understood, which has resulted in limited therapeutic options for patients afflicted with this condition. The past decade has seen a surge in new research being conducted in the field of ANOCA and VSA. This review article provides a comprehensive summary of the underlying pathophysiological mechanisms of VSA and the current therapeutic options. We also appraise the current diagnostic approach in patients with suspected VSA.
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Affiliation(s)
- Aish Sinha
- The British Heart Foundation Centre of Excellence and the National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Haseeb Rahman
- The British Heart Foundation Centre of Excellence and the National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Divaka Perera
- The British Heart Foundation Centre of Excellence and the National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
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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 acetylcholine testing among 746 consecutive Japanese patients with angina-like chest pain and unobstructed coronary artery disease. EUROPEAN HEART JOURNAL OPEN 2021; 2:oeab012. [PMID: 35919663 PMCID: PMC9242056 DOI: 10.1093/ehjopen/oeab012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/18/2021] [Indexed: 12/22/2022]
Abstract
Aims Intracoronary acetylcholine (ACh) testing is useful for the detection of epicardial spasm (ES) and coronary microvascular spasm (CMS). We retrospectively analysed the incidence of ES and CMS in consecutive Japanese patients with unobstructed coronary artery disease. Methods and results From January 1991 to February 2019, we performed intracoronary ACh testing of 1864 patients. Among these patients, a total of 746 consecutive patients (254 women, mean age 64 ± 11 years) who underwent first diagnostic angiography for suspected myocardial ischaemia and had unobstructed coronary arteries (<50%) were enrolled. Epicardial spasm was defined as ≥90% stenosis and usual chest symptoms and ischaemic ECG changes, while CMS was defined as <75% stenosis and usual chest symptoms and ischaemic ECG changes. We performed intracoronary ACh testing on both coronary arteries in 96% (716/746) of all subjects. Overall, ES was found in 329 patients (44%), whereas CMS was revealed in 40 patients (5%) including 4 patients with coexisting ES. In patients with ES, women made up 22%, and approximately three-quarters of the patients had resting chest pain. In contrast, women composed 65% (26/40) of those with CMS, and 15 patients with CMS had another chest symptom. Coronary microvascular spasm was frequently observed in the left coronary artery (LCA) but not the right coronary artery. Electrical cardioversion was necessary for two patients. Conclusions Coronary microvascular spasm was recognized in only 5% of consecutive Japanese patients with unobstructed coronary artery disease, whereas ES was revealed in 44% of those patients. Coronary microvascular spasm was often observed in women and in the LCA.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Hongou 3 choume 1-1, Ehime Prefecture, Niihama City 792-0042, Japan
| | - Tomoki Sakaue
- Department of Cardiology, Yawatahama City General Hospital, Ohira 1-638, Ehime Prefecture, Yawatahama City 796-8502, Japan
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Beck S, Pereyra VM, Seitz A, McChord J, Hubert A, Bekeredjian R, Sechtem U, Ong P. Invasive Diagnosis of Coronary Functional Disorders Causing Angina Pectoris. Eur Cardiol 2021; 16:e27. [PMID: 34276812 PMCID: PMC8280748 DOI: 10.15420/ecr.2021.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/26/2021] [Indexed: 01/16/2023] Open
Abstract
Coronary vasomotion disorders represent a frequent cause of angina and/or dyspnoea in patients with non-obstructed coronary arteries. The highly sophisticated interplay of vasodilatation and vasoconstriction can be assessed in an interventional diagnostic procedure. Established parameters characterising adequate vasodilatation are coronary blood flow at rest, and, after drug-induced vasodilation, coronary flow reserve, and microvascular resistance (hyperaemic microvascular resistance, index of microcirculatory resistance). An increased vasoconstrictive potential is diagnosed by provocation testing with acetylcholine or ergonovine. This enables a diagnosis of coronary epicardial and/or microvascular spasm. Ischaemia associated with microvascular spasm can be confirmed by ischaemic ECG changes and the measurement of lactate concentrations in the coronary sinus. Although interventional diagnostic procedures are helpful for determining the mechanism of the angina, which may be the key to successful medical treatment, they are still neither widely accepted nor applied in many medical centres. This article summarises currently well-established invasive methods for the diagnosis of coronary functional disorders causing angina pectoris.
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Affiliation(s)
- Sascha Beck
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | | | - Andreas Seitz
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Johanna McChord
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Astrid Hubert
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Raffi Bekeredjian
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
| | - Peter Ong
- Department of Cardiology and Angiology, Robert-Bosch-Krankenhaus Stuttgart, Germany
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12
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Transitional changes of acetylcholine spasm provocation test procedures. Cardiovasc Interv Ther 2019; 35:321-326. [PMID: 31641953 DOI: 10.1007/s12928-019-00624-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022]
Abstract
Intracoronary acetylcholine (ACh) testing has become popular in the world as a spasm provocation test as well as an ergonovine test. Intracoronary ACh test based on the Japanese Circulation Society guidelines is necessary to insert a temporary pace maker (PM). We analyzed the ACh spasm provocation test procedures retrospectively. We performed 1829 ACh spasm provocation testing during 28 years. We investigated the procedural approach sites of artery and vein. Femoral artery and vein approach, brachial artery and femoral vein approach, brachial artery and vein approach, radial artery and brachial vein approach, radial artery and femoral vein approach were performed in 292 patients (16.0%), 498 patients (27.2%), 589 patients (32.2%), 252 patients (13.8%), and 175 patients (9.6%), respectively. We could perform the ACh testing by the femoral artery and brachial artery in all patients, while the success rate of radial artery approach was 97.1%. We could also insert the temporary PM by the brachial vein in 94.8% (841/887) of the study patients, whereas we could insert the temporary PM in all femoral vein approach [100% (965/965)]. We experienced the pulmonary embolism by the femoral artery and vein approach in two patients, while we also had the arterio-venous fistula necessary for surgical repair in two patients by the brachial artery and vein approach. Although there was no difference about the procedure-related major complications among the various procedures, we had no pulmonary embolism or arterio-venous fistula by the radial artery and brachial vein approach. Considering the disinfection with povidone iodine, procedural performance or procedure-related complications by the ACh testing, we recommend that radial artery and brachial vein approach is more comfortable method of the future ACh testing not only for patients but also for operators.
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Sueda S, Fujimoto K, Sasaki Y, Sakaue T, Habara H, Kohno H. Acetylcholine spasm provocation test by trans-radial artery and brachial vein approach. Catheter Cardiovasc Interv 2019; 94:38-44. [PMID: 30548131 DOI: 10.1002/ccd.27970] [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: 12/15/2017] [Revised: 10/11/2018] [Accepted: 10/16/2018] [Indexed: 11/05/2022]
Abstract
BACKGROUND Temporary pace maker is necessary because of transient block or bradycardia during the intracoronary acetylcholine spasm provocation tests based on the Japanese Circulation Society guidelines. OBJECTIVES We examined the feasibility and safety of the acetylcholine spasm provocation test via the radial artery and brachial vein approach. METHODS We tried to perform the acetylcholine spasm provocation tests in 252 patients via the radial artery and brachial vein approach procedures during 5 years. Acetylcholine was injected in incremental doses of 20/50/80 μg into the right coronary artery (RCA) and 20/50/100/200 μg into the left coronary artery (LCA). Back-up pacing rate was set at 40 beats/min. Positive spasm was defined as transient ≥90% luminal narrowing and ischemic electrocardiographic change or usual chest pain. RESULTS The procedure success of radial artery and brachial vein access was 94.4% (238/252) and 93.3% (235/252), respectively. We performed 221 patients (87.7%) with acetylcholine tests by radial artery and brachial vein approach. We changed to the brachial approach due to the failures of radial artery access in 14 patients. We also changed to the femoral vein in 11 patients and internal jugular vein in two patients. Back-up pace maker rhythm was observed in 92.1% (232/252) of all study patients, while it was significantly higher in the RCA testing than that in the LCA tests (84.9% (191/225) vs. 52.2% (131/251), P < 0.001). No irreversible complication was found. CONCLUSIONS We recommend the radial artery and brachial vein approach for safety and convenience when performing the acetylcholine spasm provocation tests.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Niihama, Ehime, Japan
| | - Kaori Fujimoto
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Niihama, Ehime, Japan
| | - Yasuhiro Sasaki
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Niihama, Ehime, Japan
| | - Tomoki Sakaue
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Niihama, Ehime, Japan
| | - Hirokazu Habara
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Niihama, Ehime, Japan
| | - Hiroaki Kohno
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Niihama, Ehime, Japan.,Department of Cardiology, Tsukazaki Hospital, Himeji, Japan
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Teragawa H, Oshita C, Ueda T. Coronary spasm: It’s common, but it’s still unsolved. World J Cardiol 2018; 10:201-209. [PMID: 30510637 PMCID: PMC6259026 DOI: 10.4330/wjc.v10.i11.201] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 09/21/2018] [Accepted: 10/07/2018] [Indexed: 02/06/2023] Open
Abstract
Coronary spasm is caused by a transient coronary narrowing due to the constriction of epicardial coronary artery, which leads to myocardial ischemia. More than 50 years have passed since the first recognition of coronary spasm, and many findings on coronary spasm have been reported. Coronary spasm has been considered as having pivotal roles in the cause of not only rest angina but also exertional angina, acute coronary syndrome, and heart failure. In addition, several new findings of the mechanism of coronary spasm have emerged recently. The diagnosis based mainly on coronary angiography and spasm provocation test and the mainstream treatment with a focus on a calcium-channel blocker have been established. At a glance, coronary spasm or vasospastic angina (VSA) has become a common disease. On the contrary, there are several uncertain or unsolved problems regarding coronary spasm, including the presence of medically refractory coronary spasm (intractable VSA), or an appropriate use of implantable cardioverter defibrillator in patients with cardiac arrest who have been confirmed as having coronary spasm. This editorial focused on coronary spasm, including recent topics and unsolved problems.
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Affiliation(s)
- Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima 732-0057, Japan
| | - Chikage Oshita
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima 732-0057, Japan
| | - Tomohiro Ueda
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima 732-0057, Japan
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