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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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Ngo V, Tavoosi A, Natalis A, Harel F, Jolicoeur EM, Beanlands RSB, Pelletier-Galarneau M. Non-invasive diagnosis of vasospastic angina. J Nucl Cardiol 2023; 30:167-177. [PMID: 35322379 DOI: 10.1007/s12350-022-02948-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/30/2022]
Abstract
Vasospastic angina (VSA), or variant angina, is an under-recognized cause of chest pain and myocardial infarction, especially in Western countries. VSA leads to a declined quality of life and is associated with increased morbidity and mortality. Currently, the diagnosis of VSA relies on invasive testing that requires the direct intracoronary administration of ergonovine or acetylcholine. However, invasive vasoreactivity testing is underutilized. Several non-invasive imaging alternatives have been proposed to screen for VSA. This review aims to discuss the strengths and limitations of available non-invasive imaging tests for vasospastic angina.
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Affiliation(s)
- Vincent Ngo
- Department of Medical Imaging, Montreal Heart Institute, Montreal, QC, H1T1C8, Canada
| | - Anahita Tavoosi
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Alexandre Natalis
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Francois Harel
- Department of Medical Imaging, Montreal Heart Institute, Montreal, QC, H1T1C8, Canada
| | - E Marc Jolicoeur
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Robert S B Beanlands
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Wu YY, Mao WW, Li YF, Zhang Q, Zhang B, Sheng ZQ. Intra-brachial ergonovine, not acetylcholine, is associated with radial artery vasospasm in patients with coronary vasospasm. Acta Cardiol 2023; 78:135-141. [PMID: 35899777 DOI: 10.1080/00015385.2022.2030552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The intracoronary provocation test is expensive and may cause complications. Therefore, we investigated the sensitivity, specificity and safety of different drug- and dose-peripheral artery provocation tests in the diagnosis of coronary artery spasm (CAS). METHODS The patients who had repeated chest pain as well as both coronary and radial stenoses <50% were selected. These patients were divided into CAS group (n = 24) and control group (n = 33) after the intracoronary ergonovine provocation test. All patients underwent radial artery provocation tests at different dose-acetylcholine (200 µg, 400 µg and 800 µg) and ergonovine (60 µg, 100 µg and 160 µg). The predictive values of radial provocation tests for CAS diagnosis were analysed using receiver operator characteristic (ROC) curves. RESULTS In radial acetylcholine provocation tests, 200 µg of acetylcholine failed to induce radial artery spasm, and the radial artery stenosis degree was not significantly different between the CAS group and control group at 400 µg and 800 µg of acetylcholine (all p > 0.05). In the radial artery ergonovine provocation tests, the radial artery stenosis degree was all significantly higher in the CAS group than in the control group at the three different doses (all p < 0.05). The specificity and sensitivity of radial ergonovine provocation tests were 90.91% and 50.00% at 60 µg, 96.97% and 66.67% at 100 µg, and 90.91% and 95.83% at 160 µg. Only the radial 160 µg-ergonovine provocation test caused CAS in one case. CONCLUSION The radial acetylcholine provocation test has no diagnostic value for CAS. The radial 160 µg-ergonovine provocation test has higher sensitivity and specificity for CAS diagnosis, but its safety should be paid attention to.
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Affiliation(s)
- Ye-Yu Wu
- The Department of Cardiology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Wei-Wei Mao
- The Department of Cardiology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Ye-Fei Li
- The Department of Cardiology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Qing Zhang
- The Department of Cardiology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Bo Zhang
- The Department of Cardiology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Zhen-Qiang Sheng
- The Department of Cardiology, the Second Affiliated Hospital of Nantong University, Nantong, China
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Abstract
Vasospastic angina is a well-established cause of chest pain that is caused by coronary artery spasm. It can be clinically diagnosed during a spontaneous episode by documenting nitrate-responsive rest angina with associated transient ischaemic ECG changes but more often requires provocative coronary spasm testing with acetylcholine during coronary angiography. Vasospastic angina may result in recurrent episodes of angina (including nocturnal angina), which can progress on to major adverse cardiac events. Calcium channel blockers are first-line therapy for this condition, given their anti-anginal and cardioprotective benefits. Despite an established diagnostic and therapeutic management pathway for vasospastic angina, this diagnosis is often overlooked in patients presenting with chest pain. Thus, there is need for increased clinical awareness of vasospastic angina to improve outcomes in affected patients.
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Affiliation(s)
- John F Beltrame
- Discipline of Medicine, The University of Adelaide Adelaide Medical School, Adelaide, South Australia, Australia .,Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia.,Basil Hetzel Institute, Adelaide, South Australia, Australia
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Coronary Vasospastic Angina: A Review of the Pathogenesis, Diagnosis, and Management. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081124. [PMID: 36013303 PMCID: PMC9409871 DOI: 10.3390/life12081124] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 12/26/2022]
Abstract
Vasospastic angina (VSA) is an under-appreciated cause of chest pain. It is characterised by transient vasoconstriction of the coronary arteries and plays a significant role in the pathogenesis of stable angina and acute coronary syndromes. Complex mechanistic pathways characterised by endothelial dysfunction and smooth muscle hypercontractility lead to a broad spectrum of clinical manifestations ranging from recurrent angina to fatal arrhythmias. Invasive provocation testing using intracoronary acetylcholine or ergonovine is considered the current gold standard for diagnosis, but there is a wide variation in protocols amongst different institutions. Conventional pharmacological therapy relies on calcium channel blockers and nitrates; however, refractory VSA has limited options. This review evaluates the pathophysiology, diagnostic challenges, and management strategies for VSA. We believe global efforts to standardise diagnostic and therapeutic guidelines will improve the outcomes for affected patients.
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Bastiany A, Pacheco C, Sedlak T, Saw J, Miner SE, Liu S, Lavoie A, Kim DH, Gulati M, Graham MM. A Practical Approach to Invasive Testing in Ischemia with No Obstructive Coronary Arteries (INOCA). CJC Open 2022; 4:709-720. [PMID: 36035733 PMCID: PMC9402961 DOI: 10.1016/j.cjco.2022.04.009] [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: 10/15/2021] [Accepted: 04/26/2022] [Indexed: 11/18/2022] Open
Abstract
Up to 65% of women and approximately 30% of men have ischemia with no obstructive coronary artery disease (CAD; commonly known as INOCA) on invasive coronary angiography performed for stable angina. INOCA can be due to coronary microvascular dysfunction or coronary vasospasm. Despite the absence of obstructive CAD, those with INOCA have an increased risk of all-cause mortality and adverse outcomes, including recurrent angina and cardiovascular events. These patients often undergo repeat testing, including cardiac catheterization, resulting in lifetime healthcare costs that rival those for obstructive CAD. Patients with INOCA often remain undiagnosed and untreated. This review discusses the symptoms and prognosis of INOCA, offers a systematic approach to the diagnostic evaluation of these patients, and summarizes therapeutic management, including tailored therapy according to underlying pathophysiological mechanisms.
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Affiliation(s)
- Alexandra Bastiany
- Thunder Bay Regional Health Sciences Centre, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
- Corresponding author: Dr Alexandra Bastiany, Thunder Bay Regional Health Sciences Centre, Catheterization Laboratory, 980 Oliver Rd, Thunder Bay, Ontario P7B 6V4, Canada. Tel.: +1-807-622-3091; fax: +1-807-333-0903.
| | - Christine Pacheco
- Hôpital Pierre-Boucher, Université de Montréal, Montreal, Quebec, Canada
- Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Tara Sedlak
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaqueline Saw
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Shuangbo Liu
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrea Lavoie
- Saskatchewan Health Authority and Regina Mosaic Heart Centre, Regina, Saskatchewan, Canada
| | - Daniel H. Kim
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Martha Gulati
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Michelle M. Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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Kim JH, Park J, Yang Y, Lee S, Kim DH, Song JM, Kang DH, Park SW, Park SJ, Song JK. Percutaneous coronary intervention in patients with documented coronary vasospasm during long-term follow-up. Heart 2022; 108:1303-1309. [DOI: 10.1136/heartjnl-2021-320645] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/01/2022] [Indexed: 11/04/2022] Open
Abstract
ObjectiveAlthough recurring coronary artery spasm (CAS) may lead to the development of fixed atherosclerotic coronary stenosis (FS), the relationship between coronary atherosclerosis and CAS is still speculative. We evaluated the incidence of FS requiring percutaneous coronary intervention (PCI) in patients with documented CAS during long-term follow-up and analysed their clinical features.MethodsClinical data of 3556 patients during a median follow-up of 9.4 years after non-invasive ergonovine spasm provocation testing with echocardiographic monitoring of left ventricular wall motion (erg echo) were analysed.ResultsErg echo documented CAS in 830 (23.3%) patients, who had higher frequencies of coronary risk factors than those without CAS. Patients with documented CAS on erg echo showed significantly lower 10-year overall (90.5% vs 94.2%, p<0.001) and PCI-free (97.4% vs 98.4%, p=0.002) survival rates than those without CAS. Documented CAS was an independent factor associated with later PCI after adjustment by either Cox regression model or Fine-Gray competing risk model. There was no significant difference in baseline clinical characteristics between patients who needed later PCI and those who did not. Among 28 patients who needed later PCI after documentation of CAS, the original CAS and later PCI territory were concordant in 25 (89.3%), while 3 (10.7%) showed discordance.ConclusionsCAS is a risk factor for the development of FS requiring PCI during long-term follow-up, and warrants physicians’ vigilance and careful follow-up of patients with documented CAS and insignificant stenosis of major epicardial coronary arteries at the time of initial diagnosis.
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Abstract
Up to half of patients undergoing elective coronary angiography for the investigation of chest pain do not present with evidence of obstructive coronary artery disease. These patients are often discharged with a diagnosis of non-cardiac chest pain, yet many could have an ischaemic basis for their symptoms. This type of ischaemic chest pain in the absence of obstructive coronary artery disease is referred to as INOCA (ischaemia with non-obstructive coronary arteries). This comprehensive review of INOCA management looks at why these patients require treatment, who requires treatment based on diagnostic evaluation, what clinical treatment targets should be considered, how to treat patients using a personalised medicine approach, when to initiate treatment, and where future research is progressing.
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Affiliation(s)
- John F Beltrame
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
| | - Rosanna Tavella
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
| | - Dione Jones
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
| | - Chris Zeitz
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
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Bèze NE, Millien V, Lefèvre T, Chevalier B, Garot P, Hovasse T, Unterseeh T, Champagne S, Sanguineti F, Neylon A, Benamer H. [Methergin pour le diagnostic de l'angor spastique : voie intraveineuse ou intracoronaire ?]. Ann Cardiol Angeiol (Paris) 2021; 70:446-450. [PMID: 34635330 DOI: 10.1016/j.ancard.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Vasospastic angina is an infrequent underlying cause of angina and is under-diagnosed. Ergonovine provocation tests can be performed via intravenous or intracoronary injections. Although the safety profile of intracoronary injection has been well documented, no study has yet compared the intracoronary and intravenous injections regarding the positivity rate of the test. AIMS This study sought to compare the positivity rate of intravenous versus intracoronary injection of ergonovine in the diagnosis of vasospastic angina. METHODS Between January 2010 and February 2018, 427 patients with suspected vasospastic angina underwent an ergonovine provocation test in 2 tertiary hospitals in France and were retrospectively included in this study. Injection was performed via the intravenous or the intracoronary route. The primary endpoint was the positivity rate of the test. Propensity score matching was used to account for confounding factors. RESULTS 427 patients were included in the study. Mean age was 60.3 (+/- 12.4) years. There were 247 (58%) females and 97 (23%) smokers. The intracoronary route was used in 199 (47%) patients. The indication for the test was acute coronary syndrome for 121 (28%). No rhythmic complications or deaths were reported. After propensity-matching, the baseline characteristics of the 2 groups (148 patients in each) were comparable. The positivity rate was 24% in the intracoronary group and 9% in the intravenous group (OR [95%CI]: 3.2 [1.6, 6.4]). CONCLUSIONS Intracoronary injection of ergonovine is safe and associated with a positivity rate of the test three times higher compared to intravenous injection.
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Affiliation(s)
- Nathan El Bèze
- Cardiology department, Hôpital Foch, 40 Rue Worth, 92150Suresnes, France
| | - Vincent Millien
- Cardiology department, Centre Hospitalier de Saint Quentin, 1 Rue Michel De L'Hospital, 02100Saint Quentin, France
| | - Thierry Lefèvre
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Bernard Chevalier
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Thomas Hovasse
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Thierry Unterseeh
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Stéphane Champagne
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Francesca Sanguineti
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Antoinette Neylon
- Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480Quincy-sous-Sénart, France
| | - Hakim Benamer
- Cardiology department, Hôpital Foch, 40 Rue Worth, 92150Suresnes, France; Institut Cardiovasculaire Paris Sud, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France.
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Ham HS, Kim KH, Park J, Song YJ, Kim S, Kim DK, Seol SH, Kim DI. Feasibility of right coronary artery first ergonovine provocation test. Acta Cardiol 2021; 76:38-45. [PMID: 31707937 DOI: 10.1080/00015385.2019.1687966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Intracoronary (IC) provocation angiography is recommended when variant angina is suspected. However, specific procedure-related factors remain uncertain. METHODS Intracoronary ergonovine infusion was used for the provocation test. About 10, 20, and 40 μg of ergonovine were sequentially injected into the right coronary artery (RCA). During a negative or intermediate response or depending on the clinician's discretion, the left coronary artery (LCA) was injected with incremental doses of 20, 40, and 80 μg of ergonovine or vice versa. If significant coronary spasm or positive clinical findings were noted, the test was stopped immediately and IC nitroglycerine was injected. RESULTS We reviewed a total of 725 patients (male: 402; mean age: 58.5 years). Spasm-positive response was observed in 269 patients (37.1%), intermediate response in 113 patients (15.6%), and negative response in 343 patients (47.3%). The right radial artery approach was used in most cases (92.6%), and the RCA first approach was mainly chosen (95.0%). The provocation results in the RCA and LCA (93.4%, 381/408) were highly consistent, and the clinically significant discrepancy rate (RCA positive/LCA negative or RCA negative/LCA positive) was 1.5% (6/408). The RCA-alone provocation test can identify spasm-positive response in 93.4% of the patients (228/244). The mean procedure time was 39.9 ± 11.0 min, and approximately 3.3% (24/725) of the patients developed acute complications. CONCLUSIONS The RCA-first IC ergonovine provocation test is feasible, and the RCA-alone spasm provocation could be acceptable except in an intermediate response, highly clinically suspected cases, or high-risk patients.
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Affiliation(s)
- Hyun Seok Ham
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ki-Hun Kim
- Department of Internal Medicine, Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jino Park
- Department of Internal Medicine, Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Yeo-Jeong Song
- Department of Internal Medicine, Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Seunghwan Kim
- Department of Internal Medicine, Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Dong-Kie Kim
- Department of Internal Medicine, Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sang-Hoon Seol
- Department of Internal Medicine, Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Doo-Il Kim
- Department of Internal Medicine, Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Diagnostic and Prognostic Value of Ergonovine Echocardiography for Noninvasive Diagnosis of Coronary Vasospasm. JACC. CARDIOVASCULAR IMAGING 2020; 13:1875-1887. [PMID: 32417336 DOI: 10.1016/j.jcmg.2020.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study sought to obtain large-scale evidence supporting the clinical usefulness of ergonovine echocardiography. BACKGROUND The role of noninvasive ergonovine provocation testing with echocardiographic monitoring of ventricular wall motion (ergonovine echocardiography) needs to be defined. METHODS Clinical data of patients who underwent ergonovine echocardiography in 3 tertiary referral hospitals in South Korea were analyzed. RESULTS Ergonovine echocardiography was performed in 14,012 patients (mean age 52.8 ± 11.1 years; 6,213 [44.3%] women) after exclusion of significant coronary arterial stenosis by functional (treadmill or perfusion scan, n = 9,824) or anatomic test (invasive or computerized tomographic coronary angiography, n = 4,188). Premature termination developed in 0.4% (n = 51), and a positive result was observed in 2,144 patients (15.3%), with variable frequencies according to the diagnosis (acute coronary syndrome [38.2%], variant angina [31.8%], effort angina [14.9%], aborted sudden cardiac death [17.6%], syncope [9.9%]). There was no mortality or development of myocardial infarction during the test. During median follow-up of 11.4 (interquartile range: 7.2 to 15.8) years, death of any cause and cardiovascular death occurred in 494 and 143 patients, respectively. The 10-year overall (96.7 ± 0.2% vs. 91.5 ± 0.6%; p < 0.0001) and cardiovascular mortality-free (99.2 ± 0.1% vs. 96.7 ± 0.4%; p < 0.0001) survival rates were lower in patients with positive ergonovine echocardiography. Regarding patients with positive test results, the functional test group and the anatomic test group did not show a significant difference in the survival rates. After adjustment of age and male sex, a positive test was an independent risk factor associated with all-cause mortality (hazard ratio: 1.879, 95% confidence interval: 1.548 to 2.280; p < 0.001) and cardiovascular death (hazard ratio: 2.903, 95% confidence interval: 2.061 to 4.089; p < 0.001). CONCLUSIONS Ergonovine echocardiography for coronary vasospasm diagnosis could be safely performed even without angiographic documentation of fixed coronary stenosis depending on the clinical presentation, and provided important prognostic implication. Ergonovine echocardiography can replace the invasive spasm provocation testing, which has been overlooked unfairly.
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Park J, Kim HK, Park EA, Park JB, Lee SP, Lee W, Kim YJ, Sohn DW. Coronary Computed Tomography Angiography for the Diagnosis of Vasospastic Angina: Comparison with Invasive Coronary Angiography and Ergonovine Provocation Test. Korean J Radiol 2020; 20:719-728. [PMID: 30993923 PMCID: PMC6470084 DOI: 10.3348/kjr.2018.0847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/11/2019] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To investigate the diagnostic validity of coronary computed tomography angiography (cCTA) in vasospastic angina (VA) and factors associated with discrepant results between invasive coronary angiography with the ergonovine provocation test (iCAG-EPT) and cCTA. MATERIALS AND METHODS Of the 1397 patients diagnosed with VA from 2006 to 2016, 33 patients (75 lesions) with available cCTA data from within 6 months before iCAG-EPT were included. The severity of spasm (% diameter stenosis [%DS]) on iCAG-EPT and cCTA was assessed, and the difference in %DS (Δ%DS) was calculated. Δ%DS was compared after classifying the lesions according to pre-cCTA-administered sublingual nitroglycerin (SL-NG) or beta-blockers. The lesions were further categorized with %DS ≥ 50% on iCAG-EPT or cCTA defined as a significant spasm, and the diagnostic performance of cCTA on identifying significant spasm relative to iCAG-EPT was assessed. RESULTS Compared to lesions without SL-NG treatment, those with SL-NG treatment showed a higher Δ%DS (39.2% vs. 22.1%, p = 0.002). However, there was no difference in Δ%DS with or without beta-blocker treatment (35.1% vs. 32.6%, p = 0.643). The significant difference in Δ%DS associated with SL-NG was more prominent in patients who were aged < 60 years, were male, had body mass index < 25 kg/m², and had no history of hypertension, diabetes, or dyslipidemia. Based on iCAG-EPT as the reference, the per-lesion-based sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cCTA for VA diagnosis were 7.5%, 94.0%, 60.0%, 47.1%, and 48.0%, respectively. CONCLUSION For patients with clinically suspected VA, confirmation with iCAG-EPT needs to be considered without completely excluding the diagnosis of VA simply based on cCTA results, although further prospective studies are required for confirmation.
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Affiliation(s)
- Jiesuck Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyung Kwan Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
| | - Eun Ah Park
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.
| | - Jun Bean Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Seung Pyo Lee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Whal Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Yong Jin Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Dae Won Sohn
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
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14
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Hung MY, Kounis NG, Lu MY, Hu P. Myocardial Ischemic Syndromes, Heart Failure Syndromes, Electrocardiographic Abnormalities, Arrhythmic Syndromes and Angiographic Diagnosis of Coronary Artery Spasm: Literature Review. Int J Med Sci 2020; 17:1071-1082. [PMID: 32410837 PMCID: PMC7211159 DOI: 10.7150/ijms.43472] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 03/23/2020] [Indexed: 01/06/2023] Open
Abstract
In coronary artery spasm (CAS), an excess coronary vasoconstriction causing total or subtotal vessel occlusion could lead to syncope, heart failure syndromes, arrhythmic syndromes, and myocardial ischemic syndromes including asymptomatic myocardial ischemia, stable and unstable angina, acute myocardial infarction, and sudden cardiac death. Although the clinical significance of CAS has been underrated because of the frequent absence of symptoms, affected patients appear to be at higher risk of syncope, serious arrhythmias, and sudden death than those with classic Heberden's angina pectoris. Therefore, a prompt diagnosis has important therapeutic implications, and is needed to avoid CAS-related complications. While a definitive diagnosis is based mainly on coronary angiography and provocative testing, clinical features may help guide decision-making. We perform a literature review to assess the past and current state of knowledge regarding the clinical features, electrocardiographic abnormalities and angiographic diagnosis of CAS, while a discussion of mechanisms is beyond the scope of this review.
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Affiliation(s)
- Ming-Yow Hung
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Nicholas G Kounis
- Department of Cardiology, University of Patras Medical School, Rion, Patras, Achaia, Greece
| | - Meng-Ying Lu
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Patrick Hu
- University of California, Riverside, Riverside, California, USA.,Department of Cardiology, Riverside Medical Clinic, Riverside, California, USA
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15
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Kim SR, Choi KH, Song YB, Lee JM, Park TK, Yang JH, Hahn JY, Choi JH, Choi SH, Gwon HC. Effect of sarpogrelate and high-dose statin on the reduction of coronary spasm in vasospastic angina: A two by two factorial, pilot randomized study. Clin Cardiol 2019; 42:899-907. [PMID: 31339594 PMCID: PMC6788571 DOI: 10.1002/clc.23239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/10/2019] [Accepted: 07/17/2019] [Indexed: 12/29/2022] Open
Abstract
Background Vasospastic angina (VSA) is characterized by coronary spasm, which can be aggravated by vasoactive substances such as serotonin. Hypothesis Sarpogrelate, a selective serotonin receptor antagonist, and high‐dose statin have some effects on the reduction of coronary spasm in patients with VSA. Methods We recruited 100 patients with angiographically confirmed VSA, and randomly assigned them into four groups: sarpogrelate with high‐dose statin (Group A, n = 25), sarpogrelate with low‐dose or no statin (Group B, n = 25), placebo with high‐dose statin (Group C, n = 25), and placebo with low‐dose or no statin (Group D, n = 25). The primary endpoint was the remission of coronary spasm on 1‐year follow‐up provocation test. Results The most common site of coronary spasm was left anterior descending artery (42%). Most patients (96%) took calcium channel blockers, and 46% were treated with vasodilators. Overall, 40% of patients reported no chest pain at 1 year, and 23% showed complete remission of coronary spasm on 1‐year follow‐up provocation test. No difference was observed in symptomatic and angiographically complete remission rate between the sarpogrelate and the placebo group. Although the apolipoprotein B level at the 1‐year follow‐up was significantly lower in the high‐dose statin group, symptomatic and angiographic outcomes were not different according to statin intensity. Distal thrombolysis in myocardial infarction (TIMI) flow on initial provocation test was independently associated with angiographically complete remission. Conclusions Sarpogrelate or high‐dose statin did not significantly improve the angiographic remission rate in patients with VSA. Distal TIMI flow on initial provocation test could predict the complete remission of coronary spasm at follow‐up.
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Affiliation(s)
- So Ree Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, 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
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin-Ho Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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16
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Abstract
Coronary artery vasospasm (CVS) is an important mechanism of myocardial ischemia and produces any of the manifestations of coronary artery disease from silent myocardial ischemia, to effort-induced angina and variant angina, to acute coronary syndrome including myocardial infarction or sudden cardiac death. The pathogenesis, characteristic clinical features, diagnosis, and treatment of CVS are summarized. Emphasis is placed on correct diagnosis of CVS using pharmacological spasm provocation test, either during coronary angiography or with echocardiographic monitoring of ventricular wall motion. Current underutilization of pharmacologic provocative test at the time of coronary angiography cannot be justified, as there is no evidence supporting that the incidence of CVS is declining. Physicians' vigilance for objective documentation of CVS is necessary for appropriate management of patients with various clinical presentations of ischemic heart disease.
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Affiliation(s)
- Jae Kwan Song
- Department of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Korea.
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17
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Song YJ, Ha SJ, Lee DS, Bang WD, Shin DG, Woo Y, Cheong S, Yoo SY. Ergonovine Stress Echocardiography for the Diagnosis of Vasospastic Angina and Its Prognostic Implications in 3,094 Consecutive Patients. Korean Circ J 2018; 48:906-916. [PMID: 30238707 PMCID: PMC6158448 DOI: 10.4070/kcj.2017.0395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/14/2018] [Accepted: 04/10/2018] [Indexed: 01/30/2023] Open
Abstract
Background and Objectives Ergonovine stress echocardiography (ErgECHO) has been proposed as a noninvasive tool for the diagnosis of coronary vasospasm. However, concern over the safety of ErgECHO remains. This study was undertaken to investigate the safety and prognostic value of ErgECHO in a large population. Methods We studied 3,094 consecutive patients from a single-center registry who underwent ErgECHO from November 2002 to June 2009. Medical records, echocardiographic data, and laboratory findings obtained from follow-up periods were analyzed. Results The overall positive rate of ErgECHO was 8.6%. No procedure-related mortality or myocardial infarction (MI) occurred. Nineteen patients (0.6%) had transient symptomatic complications during ErgECHO including one who was successfully resuscitated. Cumulative major adverse cardiac events (MACEs) occurred in 14.0% and 5.1% of the patients with positive and negative ErgECHO results, respectively (p<0.001) at a median follow-up of 10.5 years. Cox regression survival analyses revealed that male sex, age, presence of diabetes, total cholesterol level of >220 mg/dL, and positive ErgECHO result itself were independent factors associated with MACEs. Conclusions ErgECHO can be performed safely by experienced physicians and its positive result may be an independent risk factor for long-term adverse outcomes. It may also be an alternative tool to invasive ergonovine-provoked coronary angiography for the diagnosis of vasospastic angina.
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Affiliation(s)
- Yeo Jeong Song
- Division of Cardiology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sang Jin Ha
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Dong Seok Lee
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Woo Dae Bang
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Dong Geum Shin
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Yeongmin Woo
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Sangsig Cheong
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Sang Yong Yoo
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea.
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18
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Wang HT, Liu WH, Chen YL. Transient sick sinus syndrome with complete atrioventricular block associated with ergonovine intake: A case report. Medicine (Baltimore) 2017; 96:e8559. [PMID: 29095320 PMCID: PMC5682839 DOI: 10.1097/md.0000000000008559] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE More mature or older women are more likely to undergo in vitro fertilization and embryo implant. These women have a greater chance of receiving ergonovine therapy because of a suspected abortion. We present this case report to call attention to a latent lethal adverse effect in everyday obstetric practice using ergonovine. It requires more attention and close monitoring PATIENT CONCERNS:: We presented the case of a 38-year-old female patient with general weakness and mild chest tightness after ergonovine use. DIAGNOSES She was diagnosed as transient sick sinus syndrome and complete atrioventricular block with junctional escape rhythm after diagnostic work up. INTERVENTIONS Conservative treatment with discontinuation of ergonovine and bed rest. OUTCOMES Her sinus rhythm returned to normal the day after ergonovine was discontinued. The patient remained symptom-free since recovery of her sinus rhythm. LESSONS Ergonovine may cause symptomatic and lethal bradyarrhythmia. Withdrawal of the causative medication and adequate supportive care can lead to a favorable outcome in these patients. More related cases should be reported. Further evaluation for treatment and prognosis are necessary.
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Affiliation(s)
| | - Wen-Hao Liu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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19
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Ciliberti G, Seshasai SRK, Ambrosio G, Kaski JC. Safety of intracoronary provocative testing for the diagnosis of coronary artery spasm. Int J Cardiol 2017. [DOI: 10.1016/j.ijcard.2017.05.109] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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20
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Kang EJ, Kim MH, De Jin C, Seo J, Kim DW, Yoon SK, Park TH, Lee KN, Choi SI, Yoon YE. Noninvasive detection of coronary vasospastic angina using a double-acquisition coronary CT angiography protocol in the presence and absence of an intravenous nitrate: a pilot study. Eur Radiol 2016; 27:1136-1147. [PMID: 27380904 DOI: 10.1007/s00330-016-4476-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 05/04/2016] [Accepted: 06/20/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To evaluate the feasibility of a double-acquisition coronary CT angiography (CCTA) protocol in the presence and absence of an intravenous (IV) vasodilator infusion for detecting vasospastic angina. METHODS Twenty patients with a high clinical probability of vasospastic angina were enrolled. All subjects underwent baseline CCTA without a vasodilator in the early morning followed by a catheterized coronary angiography with ergonovine provocation test. Within 3 days, all subjects underwent repeat CCTA during a continuous IV infusion of nitrate. Vasospastic angina as detected by CCTA was defined as significant stenosis (≥50 %) with negative remodelling without definite plaques or diffuse small diameter (<2 mm) of a major coronary artery with a beaded appearance on baseline CT that completely dilated on IV nitrate CT. The CCTA results were compared to the catheterized ergonovine provocation test as the reference standard. RESULTS Among 20 patients, the catheterized ergonovine provocation test detected vasospasm in 15 patients. The sensitivity, specificity, positive predictive value and negative predictive value of CCTA in a per-patient-based analysis were 73, 100, 100 and 56 %, respectively. CONCLUSIONS Double-acquisition CCTA in the presence and absence of IV infusion of nitrate allows noninvasive detection of vasospastic angina with moderate sensitivity and high specificity. KEY POINTS • Limited data exist regarding the efficacy of CCTA in detecting vasospastic angina. • We propose a double-acquisition CCTA protocol with and without IV nitrate injections. • This protocol provides 100% specificity and moderate sensitivity (73%) in spasm detection.
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Affiliation(s)
- Eun-Ju Kang
- Department of Radiology, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Moo Hyun Kim
- Department of Cardiology, College of Medicine, Dong-A University, 3-1 Dongdaeshin-Dong, Seo-Gu, Busan, 602-715, Republic of Korea. .,Global Clinical Trial Center, Dong-A University Hospital, Busan, Republic of Korea.
| | - Cai De Jin
- Department of Cardiology, College of Medicine, Dong-A University, 3-1 Dongdaeshin-Dong, Seo-Gu, Busan, 602-715, Republic of Korea.,Global Clinical Trial Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Jeongmin Seo
- Department of Cardiology, College of Medicine, Dong-A University, 3-1 Dongdaeshin-Dong, Seo-Gu, Busan, 602-715, Republic of Korea
| | - Dong Won Kim
- Department of Radiology, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Seong Kuk Yoon
- Department of Radiology, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Tae-Ho Park
- Department of Cardiology, College of Medicine, Dong-A University, 3-1 Dongdaeshin-Dong, Seo-Gu, Busan, 602-715, Republic of Korea
| | - Ki-Nam Lee
- Department of Radiology, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Sang Il Choi
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Yeonyee Elizabeth Yoon
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
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21
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Abstract
The frequency, presentation, prognosis, and treatment of myocardial ischemia differ in men and women. A large proportion of women who have "normal" coronary arteries on angiography without any significant evidence of flow-limiting disease also have biochemical or imaging evidence of myocardial ischemia. In these women it is believed to be a dysfunction of coronary microcirculation and/or macrocirculation, or vasotonic angina (VA), that leads to abnormal vasoconstriction, and potentially to myocardial infarction, ventricular arrhythmias, and sudden death. Despite having a "normal" or near normal coronary angiography, these women should therefore undergo additional testing with acetylcholine to assess endothelial function. Long-term survival is believed to be relatively good. Predictors of poorer prognosis include documentation of severe endothelial dysfunction and presence of concurrent angiographycally visible coronary atherosclerosis. Because atherosclerosis is common in patients with VA, medical and lifestyle interventions for preventing or treating atherosclerosis should be implemented when appropriate. Angiotensin converting enzyme inhibitors are the mainstays of medical therapy for VA. Other agents have been tried with variable success, including beta-blockers. There are no available data on any specific treatment of VA in women (versus men).
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22
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Vrints CJ, Senior R, Crea F, Sechtem U. Assessing suspected angina: requiem for coronary computed tomography angiography or exercise electrocardiogram? Eur Heart J 2016; 38:1792-1800. [DOI: 10.1093/eurheartj/ehw065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 01/29/2016] [Indexed: 01/19/2023] Open
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23
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Nakanishi M, Masumo K, Oota T, Kato T, Imanishi T. Ventricular tachycardia observed during cesarean section in a patient without structural cardiac disease. JA Clin Rep 2015; 1:23. [PMID: 29497655 PMCID: PMC5818695 DOI: 10.1186/s40981-015-0019-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/23/2015] [Indexed: 12/04/2022] Open
Abstract
A 32-year-old gravida 2, para 1 woman without structural cardiac disease was scheduled for her second cesarean section under combined spinal and epidural anesthesia (CSEA). She had stable hemodynamics after delivery; however, 16 min after the application of uterotonics, ventricular tachycardia (VT) with a heart rate (HR) of 150 bpm appeared. VT lasted for <30 s, and her hemodynamics remained stable. Ventricular arrhythmia frequently appeared for 3 min, and the HR at sinus rhythm was approximately 90 bpm. After the discontinuation of oxytocin, VT did not reappear. A postoperative 12-lead electrocardiogram showed first-degree atrioventricular block, but echocardiography performed 2 days later did not reveal any structural abnormalities. Autonomic nervous imbalance induced by CSEA, ephedrine, and oxytocin, as well as ergometrine may cause intraoperative VT during cesarean section in patients without structural cardiac disease.
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Affiliation(s)
- Mika Nakanishi
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Kaoru Masumo
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Takako Oota
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Takeshi Kato
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Toshihiro Imanishi
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
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24
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Jang HJ, Kim TH, Kwon SW, Kim JY, Kim JS, Lee HJ, Park JS, Choi RK, Choi YJ, Shim WH. Left ventricular end diastolic pressure for detection of intracoronary ergonovine-induced myocardial ischemia. Herz 2015; 41:320-5. [PMID: 26545603 DOI: 10.1007/s00059-015-4368-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 09/07/2015] [Accepted: 09/27/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recent consensus on variant angina defines significant spasm as total or subtotal occlusion of a coronary artery. However, the clinical significance of "less-than-subtotal" spasm needs to be reappraised, especially if the coronary spasm is combined with chest pain. Therefore, we evaluated the feasibility of left ventricular end diastolic pressure (LVEDP) as a tool to detect myocardial ischemia during ergonovine provocation testing. METHODS After achieving two access sites, 29 patients underwent successful LVEDP monitoring using 5-Fr pigtail catheters during ergonovine provocation tests. Patients were divided into two groups based on the occurrence of anginal symptoms. RESULTS Of the 29 patients, 16 (55 %) patients had anginal symptoms. LVEDP was significantly increased in the symptomatic group compared with the nonsymptomatic group (∆LVEDP 5.6 ± 4.2 vs. 1.2 ± 2.0 mmHg, p = 0.002). However, of the 16 patients with anginal symptoms, positive provocation test results were confirmed in only six patients (38 %) as per the traditional standard (> 90 % inducible spasm of the epicardial coronary artery). CONCLUSION Compared with the traditional standard, LVEDP may have advantages in terms of elucidating anginal symptoms in patients suspected of having coronary vasospasm when performing ergonovine provocation tests.
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Affiliation(s)
- H-J Jang
- Division of Cardiology, Sejong General Hospital, Bucheon-si, Gyeonggi-do Korea, Republic of Korea
| | - T-H Kim
- Division of Cardiology, Sejong General Hospital, Bucheon-si, Gyeonggi-do Korea, Republic of Korea.
| | - S W Kwon
- Division of Cardiology, Inha University Hospital, Incheon, Republic of Korea
| | - J-Y Kim
- Division of Neurology, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
| | - J S Kim
- Division of Cardiology, Sejong General Hospital, Bucheon-si, Gyeonggi-do Korea, Republic of Korea
| | - H J Lee
- Division of Cardiology, Sejong General Hospital, Bucheon-si, Gyeonggi-do Korea, Republic of Korea
| | - J S Park
- Division of Cardiology, Sejong General Hospital, Bucheon-si, Gyeonggi-do Korea, Republic of Korea
| | - R K Choi
- Division of Cardiology, Sejong General Hospital, Bucheon-si, Gyeonggi-do Korea, Republic of Korea
| | - Y J Choi
- Division of Cardiology, Sejong General Hospital, Bucheon-si, Gyeonggi-do Korea, Republic of Korea
| | - W-H Shim
- Division of Cardiology, Sejong General Hospital, Bucheon-si, Gyeonggi-do Korea, Republic of Korea
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25
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Okada M. Author's reply. J Cardiol 2015; 66:539-40. [PMID: 26362591 DOI: 10.1016/j.jjcc.2015.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 03/16/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Munemasa Okada
- Yamaguchi University Graduate School of Medicine, Ube, Japan.
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26
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MacAlpin RN. Some observations on and controversies about coronary arterial spasm. Int J Cardiol 2014; 181:389-98. [PMID: 25555285 DOI: 10.1016/j.ijcard.2014.12.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 12/04/2014] [Accepted: 12/20/2014] [Indexed: 10/24/2022]
Abstract
The pathogenesis, clinical features, diagnosis, and treatment of spasm of epicardial coronary arteries are reviewed briefly, especially with regard to some issues that remain controversial. For diagnosis, emphasis is placed on the need for objective observations during an attack, even if that requires an attempt at pharmacologic provocation during coronary arteriography, or during echocardiography when prior arteriography has demonstrated the absence of severe coronary stenosis.
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Affiliation(s)
- Rex N MacAlpin
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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Zaya M, Mehta PK, Merz CNB. Provocative testing for coronary reactivity and spasm. J Am Coll Cardiol 2014; 63:103-9. [PMID: 24201078 PMCID: PMC3914306 DOI: 10.1016/j.jacc.2013.10.038] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 09/10/2013] [Accepted: 10/06/2013] [Indexed: 01/29/2023]
Abstract
Coronary spasm is an important and often overlooked etiology of chest pain. Although coronary spasm, or Prinzmetal's angina, has been thought of as benign, contemporary studies have shown serious associated adverse outcomes, including acute coronary syndrome, arrhythmia, and death. Definitive diagnosis of coronary spasm can at times be difficult, given the transience of symptoms. Numerous agents have been historically described for provocative testing. We provide a review of published data for the role of provocation testing in the diagnosis of coronary spasm.
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Affiliation(s)
- Melody Zaya
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Puja K Mehta
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California.
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Yoon JW, Lee YS, Kim DK, Choi YH, Kim DJ, Lee JJ, Ahn HS, Cho WH. Coronary artery vasospasm after atrial septal defect surgery. Yeungnam Univ J Med 2014. [DOI: 10.12701/yujm.2014.31.2.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jin Won Yoon
- Division of Cardiology, Department of Internal Medicine, Sahmyook Medical Center, Seoul, Korea
| | - Young Soo Lee
- Division of Cardiology, Department of Internal Medicine, Sahmyook Medical Center, Seoul, Korea
| | - Dong Keun Kim
- Division of Cardiology, Department of Internal Medicine, Sahmyook Medical Center, Seoul, Korea
| | - Young Hoon Choi
- Division of Cardiology, Department of Internal Medicine, Sahmyook Medical Center, Seoul, Korea
| | - Dong-Ju Kim
- Division of Cardiology, Department of Internal Medicine, Sahmyook Medical Center, Seoul, Korea
| | - Jae Jin Lee
- Department of Thoracic and Cardiovascular Surgery, Sahmyook Medical Center, Seoul, Korea
| | - Hyo Seung Ahn
- Division of Cardiology, Department of Internal Medicine, Sahmyook Medical Center, Seoul, Korea
| | - Wook Hyun Cho
- Division of Cardiology, Department of Internal Medicine, Sahmyook Medical Center, Seoul, Korea
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Yoo SY, Song SG, Lee JH, Shin ES, Kim JS, Park YH, Kim J, Chun KJ, Kim JH. Efficacy of cilostazol on uncontrolled coronary vasospastic angina: a pilot study. Cardiovasc Ther 2013; 31:179-85. [PMID: 22953758 PMCID: PMC3654168 DOI: 10.1111/j.1755-5922.2012.00312.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Although an angina attack by vasospastic angina (VSA) can usually be relieved or controlled with nitrates and calcium channel blockers (CCBs), there are some patients who cannot be controlled even by higher doses and combinations of these drugs. Cilostazol is a selective inhibitor of phosphodiesterase 3 that increases intracellular cyclic adenosine monophosphate (cAMP) contents. A stimulation of cAMP signal transduction increases coronary nitric oxide production. We examined whether cilostazol improved angina symptoms in patients with VSA uncontrolled by conventional treatment. METHODS This study was conducted in a prospective, multicenter, nonrandomized manner. The subject consisted of 21 patients (13 men, 57 ± 9 year-old) who were diagnosed with VSA and had at least two angina attacks during the past 1 week despite of conventional medications such as CCBs and/or nitrates. They took cilostazol 100 mg twice daily for 2 weeks in addition to the conventional medications. The patients recorded the frequency of angina attack and wrote down the numeric rating scale of a "severity of angina attack" while taking conventional medications and cilostazol for 2 weeks, and also recorded an averaged scale or total number of event during the last week at the time of the assessment. Using the Wilcoxon rank-sum test, we compared the changes in the scores of frequency and severity of angina attack before and after adding cilostazol to the conventional medications. RESULTS After adding cilostazol to the conventional medications, there were 78.9% relative reduction of the score of angina intensity and 73.5% of angina frequency (P < 0.001). There were four patients (19%) who were forced to stop cilostazol due to headache as an adverse event. CONCLUSIONS Cilostazol appears to be an effective therapy in VSA uncontrolled with conventional medical treatment. A further prospective, randomized, placebo-controlled study will be needed to validate this result.
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Affiliation(s)
- Sang-Yong Yoo
- Department of Internal Medicine, Division of Cardiology, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneun, South Korea
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A series of unfortunate events: prinzmetal angina culminating in transmural infarction in the setting of acute gastrointestinal hemorrhage. Case Rep Cardiol 2013; 2013:641348. [PMID: 24826293 PMCID: PMC4008281 DOI: 10.1155/2013/641348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 04/04/2013] [Indexed: 11/18/2022] Open
Abstract
Prinzmetal angina or vasospastic angina is a clinical phenomenon that is often transient and self-resolving. Clinically it is associated with ST elevations on the electrocardiogram, and initially it may be difficult to differentiate from an acute myocardial infarction. The vasospasm induced in this setting occurs in normal or mildly to moderately diseased vessels and can be triggered by a number of etiologies including smoking, changes in autonomic activity, or drug ingestion. While the ischemia induced is usually transient, myocardial infarction and life-threatening arrhythmias can occur in 25% of cases. We present the case of a 65-year-old female where repetitive intermittent coronary vasospasm culminated in transmural infarction in the setting of gastrointestinal bleeding. This case highlights the mortality associated with prinzmetal angina and the importance of recognizing the underlying etiology.
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Cortell A, Marcos-Alberca P, Almería C, Rodrigo JL, Pérez-Isla L, Macaya C, Zamorano JL. Ergonovine stress echocardiography: Recent experience and safety in our centre. World J Cardiol 2010; 2:437-42. [PMID: 21191545 PMCID: PMC3011139 DOI: 10.4330/wjc.v2.i12.437] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 09/10/2010] [Accepted: 09/17/2010] [Indexed: 02/06/2023] Open
Abstract
AIM To study recent experience and safety of ergonovine stress echocardiography in our centre. METHODS In this study we collected the clinical variables of patients referred since 2002 for ergonovine stress echocardiography, in addition to indications, the results of this test, complications, blood pressure and heart rate values during the test and the number and results of tests requested before this technique. RESULTS We performed 40 tests in 38 patients, 2 tests were carried out to verify therapy efficacy. The prevalence of classic cardiovascular risk factors was low and the most frequent indication was chest pain (57.5%). Coronary angiography was performed in 32 patients, and showed normal coronary arteries in 27 patients and non-significant stenosis in 5 cases. In 16 patients, coronary angiography was carried out after a positive or inconclusive ischemia test. Another 6 patients had a normal stress test (5 exercise electrocardiography tests and 1 nuclear imaging test). Of the 40 ergonovine stress echocardiography tests, 6 were positive (4 in the right coronary artery territory and 2 in the circumflex coronary artery territory), all of them by echocardiographic criteria, and by electrocardiographic criteria in only 3 (50%). The presence of non-significant coronary artery stenosis was more frequent in patients with positive ergonovine stress echocardiography (50% vs 6%, P = 0.038), and were related to ischemic territory. During the maximum stress stage, there was a higher systolic (130.26 ± 19.17 mmHg vs 136.58 ± 27.27 mmHg, 95% CI: -12.77 to 0.14 mmHg, P = 0.055) and diastolic blood pressure (77.89 ± 13.49 mmHg vs 83.95 ± 15.73 mmHg, 95% CI: -10.41 to -1.69 mmHg, P = 0.008) than at the baseline stage, and the same was registered with heart rate (73 ± 10.96 beats/min vs 79.79 ± 11.72 beats/min, 95% CI: -9.46 to -4.11 beats/min, P < 0.01). Nevertheless, there were only 2 hypertensive reactions during the last stage, which did not force a premature end to the test, without sustained tachy or bradyarrhythmias, and the technique was well tolerated in 58% of cases. A unique complication (2.5%) of this test was a prolonged vasospasm with a slight increase in necrosis biomarkers, however, this was without repercussion. CONCLUSION Ergonovine stress echocardiography can be performed with safety, is well tolerated in the majority of cases, and is useful for determining the ischemia mechanism in selected cases.
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Affiliation(s)
- Alejandro Cortell
- Alejandro Cortell, Pedro Marcos-Alberca, Carlos Almería, José L Rodrigo, Leopoldo Pérez-Isla, Carlos Macaya, José Luis Zamorano, University Clinic San Carlos, Cardiovascular Institute, Profesor Martín Lagos Street, Madrid 28040, Madrid comunity, Spain
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Abstract
Abnormal coronary vasoconstriction, or coronary spasm, can be the result of several factors, including local and neuroendocrine aberrations. It can manifest clinically as a coronary syndrome and plays an important role in the genesis of myocardial ischemia. Over the past half century, coronary angiography allowed the in vivo demonstration of spasm in patients who fit the initial clinical description of the condition as reported by Prinzmetal et al. Several clinical, basic, and more recently, genetic studies have provided insight into the pathogenesis, manifestations, and therapy of this condition. It is not uncommonly encountered in patients with coronary syndromes and absence of clearly pathologic lesions on angiography. Provocation tests utilizing pharmacologic and nonpharmacologic stimuli combined with imaging (echocardiography or coronary angiography) can help make the correct diagnosis. The use of calcium channel blockers and long-acting nitrates is currently considered standard of care and the overall prognosis appears to be good. The recent discovery of genetic abnormalities predisposing to abnormal spasm of the coronaries has stimulated interest in the development of targeted therapies for the management of this condition.
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Guindolet D, Monsel F, Estève JB, Sergent J, Nallet O. [Non invasive methylergometrine test should be carried out after cardiac arrest due to coronary spasm?]. Ann Cardiol Angeiol (Paris) 2010; 59:311-3. [PMID: 20851379 DOI: 10.1016/j.ancard.2010.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 08/04/2010] [Indexed: 11/16/2022]
Abstract
A 59-year-old man was admitted after cardiac arrest with successful reanimation. There was no significant coronary lesion. We conclude to the diagnosis of coronary spasm after the occurrence of a chest pain with anterior ST elevation reversible with intravenous nitrates. One month later, non-invasive methylergometrine test was carried out and complicated by a cardiac arrest due to complete heart block and asystole treated by chest compression, molsidomine and epinephrine. No cardiac event occurred within the following six months. Technique (invasive versus not invasive) and indication of methylergometrine test for the follow-up of severe manifestations of coronary spasm should be better specified in international guidelines.
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Affiliation(s)
- D Guindolet
- Fédération de cardiologie, centre hospitalier intercommunal, rue du Général-Leclerc, 93370 Montfermeil, France
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Lee JH, Lee H, Bae MH, Kwon YS, Lee JH, Ryu HM, Park Y, Yang DH, Park HS, Cho Y, Chae SC, Jun JE, Park WH. Gender differences among korean patients with coronary spasm. Korean Circ J 2009; 39:423-7. [PMID: 19949588 PMCID: PMC2771798 DOI: 10.4070/kcj.2009.39.10.423] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Revised: 05/21/2009] [Accepted: 06/01/2009] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The gender differences among Korean patients with coronary spasm have not been defined. We thus determined the gender differences among Korean patients with coronary spasm. SUBJECTS AND METHODS Patients with chest pain and/or syncope who were admitted to Kyungpook National University Hospital between January 2001 and August 2008 were included. Provocation of coronary vasospasm with intracoronary ergonovine maleate was performed when baseline coronary angiography showed no significant stenosis or there was a strong clinical suspicion of coronary spasm. The clinical characteristics were analyzed from 104 consecutive patients (56+/-9 years of age; 21 females) who were diagnosed with coronary spasm. RESULTS Female patients were younger (52+/-7 vs. 57+/-10 years, p=0.046) with lower rates of smoking and alcohol consumption histories than male patients (19% vs. 65%, p<0.001; and 43% vs. 89%, p<0.001, respectively). The other clinical characteristics were not significantly different, except for the triglyceride levels. CONCLUSION The majority of patients with coronary spasm were males who were smokers and alcohol consumers. The female patients had lower rates of smoking and alcohol consumption, and they were younger than the male patients. Further studies are needed to investigate the relevance of gender differences in the pathogenesis of coronary spasm.
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Affiliation(s)
- Ju Hwan Lee
- Department of Internal Medicine, CHA University, CHA Gumi Medical Center, Gumi, Korea
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Sueda S, Oshita A, Nomoto T, Izoe Y, Kohno H, Fukuda H, Mineoi K, Ochi T, Uraoka T. Recommendations for performing acetylcholine tests safely: STOP dangerous complications induced by acetylcholine tests (STOP DCIAT). J Cardiol 2008; 51:131-4. [PMID: 18522786 DOI: 10.1016/j.jjcc.2008.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Revised: 12/11/2007] [Accepted: 01/10/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVES We examined some recommendations for performing acetylcholine (ACh) tests safely. METHODS AND RESULTS We performed 1000 ACh tests from 1991 to December 2004. ACh was injected in incremental doses of 20/50/80 microg into the RCA and of 20/50/100 microg into the LCA. During these periods, we encountered various major/minor complications; 12 ventricular tachycardia (1.2%) necessary one dc, one ventricular fibrillation (0.1%) necessary dc, 3 shock like the left main stem spasm (0.3%), one cardiac tamponade necessary surgical drainage (0.1%), and 164 Paf (164/959:17.1%) necessary administration of antiarrhythmic agents to sinus rhythm in about one third patients (31.7%). We did not experience irreversible severe complications, such as acute myocardial infarction or death. RECOMMENDATIONS (1) Stand by direct current with pasting, (2) Thump version when ventricular tachycardia or fibrillation occurred, (3) Over infusion to avoid hypovolemia, (4) Perform angiography before complete spasm provocation if a severe spasm, (5) Drainage if cardiac tamponade occurred, (6) Cibenzoline or disopyramid administration when ACh induced paroxysmal atrial fibrillation, (7) Incremental ACh dose up should be performed, (8) Administer small amount of noradrenaline if shock observed and (9) Test shot should be performed before 1-min angiography. CONCLUSIONS We recommend STOP DCIAT for performing ACh tests safely.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Saiseikai Saijo Hospital, 269-1 Tsuitachi, Saijo, Ehime 793-0027, Japan.
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Coronary artery spasm--clinical features, diagnosis, pathogenesis, and treatment. J Cardiol 2008; 51:2-17. [PMID: 18522770 DOI: 10.1016/j.jjcc.2008.01.001] [Citation(s) in RCA: 360] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2007] [Accepted: 12/25/2007] [Indexed: 12/22/2022]
Abstract
Coronary (artery) spasm plays an important role in the pathogenesis of ischemic heart disease, including stable angina, unstable angina, myocardial infarction, and sudden death. The prevalence of coronary spasm differs among populations, is higher in Japan and Korea than in the Western countries probably due to genetic as well as environmental factors. Coronary spasm occurs most often from midnight to early morning and is usually not induced by exercise in the daytime. The attacks of coronary spasm are associated with either ST segment elevation or depression, or negative U wave on ECG. Patients with multi-vessel coronary spasm may suffer from lethal arrhythmia, including advanced AV block, ventricular tachycardia or fibrillation, or even sudden death, and they are often resistant to conventional medical therapy including Ca-channel blockers (CCBs). Endothelial nitric oxide (NO) activity is reduced and markers of oxidative stress are elevated in patients with coronary spasm. Thrombogenesis is enhanced and plasma levels of hsCRP and P-selection are elevated in patients with coronary spasm. Thus, patients with coronary spasm have endothelial dysfunction and are suffering from a low-grade chronic inflammation. Polymorphisms of endothelial NO synthase, smoking, and low-grade inflammation are the most important risk factors for coronary spasm. Coronary spasm is a hyper-contraction of coronary smooth muscle triggered by an increase of intracellular Ca2+ in the presence of an increased Ca2+ sensitivity. It has been shown that RhoA/ROCK pathway is involved in Ca2+ sensitivity and that the reduced endothelial NO activity results in increased Ca2+ sensitivity through enhanced RhoA/ROCK pathway. Accordingly, it is possible that in addition to CCBs, RhoA/ROCK pathway blockers may prove to be useful for the treatment of coronary spasm.
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Nelson SM, Greer IA. Thromboembolic events in pregnancy: pharmacological prophylaxis and treatment. Expert Opin Pharmacother 2007; 8:2917-31. [DOI: 10.1517/14656566.8.17.2917] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hirano Y, Uehara H, Nakamura H, Ikuta S, Nakano M, Akiyama S, Ishikawa K. Diagnosis of vasospastic angina: Comparison of hyperventilation and cold-pressor stress echocardiography, hyperventilation and cold-pressor stress coronary angiography, and coronary angiography with intracoronary injection of acetylcholine. Int J Cardiol 2007; 116:331-7. [DOI: 10.1016/j.ijcard.2006.03.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Accepted: 03/25/2006] [Indexed: 10/24/2022]
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Coma-Canella I, Castano S, Macías A, Calabuig J, Artaiz M. Ergonovine test in angina with normal coronary arteries. Is it worth doing it? Int J Cardiol 2006; 107:200-6. [PMID: 16412797 DOI: 10.1016/j.ijcard.2005.03.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2004] [Revised: 02/21/2005] [Accepted: 03/02/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with angina and normal coronary arteries are often misdiagnosed with having non-cardiac pain. Although vasospasm is a well-known entity, spasm provocation is not routinely done in the majority of hospitals at present. MATERIALS AND METHODS One hundred and sixty two consecutive patients with thoracic pain and normal coronary arteries were retrospectively studied. The characteristics of pain were analysed. One hundred and sixty one non-invasive tests (with and without imaging) were done to 126 patients before angiography. Increasing doses of ergonovine (from 1 to 30 microg) were injected into the coronary arteries to provoke coronary spasm. The correlation between ergonovine-induced spasm and non-invasive tests was studied. RESULTS Oppressive thoracic pain suggestive of angina was present in 144 patients. It occurred at rest in 59 patients, only at night in 14, with effort in 40, and it was mixed in 31. Non-oppressive atypical pain was reported by 18 patients. Non-invasive tests were 94 positive, 60 negative and 7 non-diagnostic. Ergonovine test elicited coronary spasm in 85 patients (52.5%). No significant correlation was found between the positivity of a non-invasive test and ergonovine-induced spasm. CONCLUSIONS More than half of the patients with angina and normal coronary arteries can be diagnosed with vasospastic angina if ergonovine test is performed. Even patients with a negative non-invasive test maybe sent to coronary angiography when vasospastic angina is suspected, in order to have an accurate diagnosis.
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Affiliation(s)
- Isabel Coma-Canella
- Department of Cardiology, Clínica Universitaria, Facultad de Medicina, Universidad de Navarra, Avenida de Pio XII, 36. 31008, Pamplona, Spain.
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Sueda S, Kohno H, Fukuda H, Ochi N, Kawada H, Hayashi Y, Uraoka T. Clinical impact of selective spasm provocation tests: comparisons between acetylcholine and ergonovine in 1508 examinations. Coron Artery Dis 2005; 15:491-7. [PMID: 15585990 DOI: 10.1097/00019501-200412000-00006] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are few reports regarding the concordance of coronary arterial response between acetylcholine (ACh) and ergonovine (ER) spasm provocation tests. OBJECTIVES We attempted to perform selective spasm provocation tests to examine the incidence of provoked spasm in patients who had undergone first coronary angiography as much as possible and we compared the coronary arterial response and clinical usefulness between selective intracoronary injection of ACh and intracoronary administration of ER. METHODS We performed 1508 selective spasm provocation tests, consisting of 873 ACh tests and 635 ER tests, from 1991 to 2002. We examined the frequency of provoked spasms of each agent retrospectively. ACh was injected in incremental doses of 20, 50 and 80 microg into the right coronary artery and 20, 50 and 100 microg into the left coronary artery. ER was administered as 10 microg/min over 4 min for a maximal dose of 40 microg in the right coronary artery and as 16 microg/min over 4 min for a total dose of 64 microg in the left coronary artery. Coronary spasm was defined as transient >99% luminal narrowing. RESULTS Intracoronary ACh provoked spasms in 36.0% of patients and intracoronary ER induced spasms in 29.8% of patients. In patients with ischemic heart disease, the incidence of provoked spasms was not different between ACh tests (50.9%) and ER tests (43.8%). In contrast, the frequency of provoked spasms with ACh tests was significantly higher than that with ER tests (11.0% compared with 6.4%, P<0.05) in patients without ischemic heart disease. Moreover, ACh provoked more spasms in patients without fixed stenosis than ER (36.2% compared with 25.5%, P<0.01) and multiple spasms were frequently observed when performing ACh tests (40.0% compared with 27.0%, P<0.01). Major complications were observed in 1.4% of patients with ACh tests and in 0.2% of patients with ER tests. The need for intracoronary administration of isosorbide dinitrate to relieve coronary spasms during ER testing before performing another coronary artery test was more frequently observed in ACh tests (5.04% compared with 1.49%, P<0.01). However, no serious irreversible complications, such as death or acute myocardial infarction, were observed in this study. There was a significant difference in sex, history of smoking and hyperlipidemia between patients with and without spasms for both tests, whereas no difference in age or hypertension was observed in either test. CONCLUSION Thus, both selective ACh and ER tests were useful as spasm provocation tests.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Saiseikai Saijo HospitalbDepartment of Cardiology, Kita Medical Association Hospital, Ehime, Japan.
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Adlam D, Azeem T, Ali T, Gershlick A. Is there a role for provocation testing to diagnose coronary artery spasm? Int J Cardiol 2005; 102:1-7. [PMID: 15939093 DOI: 10.1016/j.ijcard.2004.07.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2004] [Accepted: 07/23/2004] [Indexed: 10/25/2022]
Abstract
Spontaneous coronary artery spasm is an important cause of morbidity both in patients with coronary artery disease and in those with variant angina. A number of pharmacological agents have been identified which can provoke coronary artery spasm in susceptible patients. The role of provocation testing in the clinical diagnosis of coronary spasm is controversial. This is reflected by variations in the clinical use of provocation testing between specialist cardiac centres. Provocation testing appears to be a sensitive method of identifying patients with variant angina and active disease but such patients can often be diagnosed clinically. The specificity is less clear. There is little evidence that altering patient therapy on the basis of a positive test modifies prognosis. There may be a role for provocation testing in rare patients with refractory disease to identify a target site for coronary stenting. A more widespread use of these tests in patients with undiagnosed chest pain syndromes would not currently be recommended.
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Affiliation(s)
- David Adlam
- Department of Cardiology, Glenfield Hospital, Groby Road, Leicester LE3 9QP, England.
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Kim MH, Park EH, Yang DK, Park TH, Kim SG, Yoon JH, Cha KS, Kum DS, Kim HJ, Kim JS. Role of vasospasm in acute coronary syndrome: insights from ergonovine stress echocardiography. Circ J 2005; 69:39-43. [PMID: 15635200 DOI: 10.1253/circj.69.39] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previous studies have shown that ergonovine stress echocardiography (ESE) may be a valuable noninvasive tool for the diagnosis of vasospasm after the confirmation of no significant fixed stenosis. METHODS AND RESULTS From May 1999 to January 2002, 52 patients who presented with acute coronary syndrome (ACS) and had normal or near-normal coronary angiograms were enrolled. A 50 microg bolus of ergonovine was given intravenously at 5-min intervals, until a positive result was observed or a total dose of 350 microg was given. After the ergonovine injection, positive results were found in 25 (48%) of 52 patients: 5 (26%) of 19 with unstable angina, 10 (53%) of 19 non-ST elevation myocardial infarction (MI) and 10 (71%) of 14 patients with ST elevation MI. Using univariate analysis, the elevation of troponin concentration, clinical diagnosis of MI, and ST segment elevation on initial electrocardiographic were significantly associated with positive stress test results. CONCLUSIONS Despite the limitation that coronary spasm was not confirmed angiographically with ergonovine provocation, ESE may be a useful technique for the noninvasive diagnosis of vasospasm.
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Affiliation(s)
- Moo Hyun Kim
- Section of Cardiology, Dong-A Medical College, Busan, South Korea.
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Lee KJ, Lee SH, Hong KP, Park JE, Seo JD, Gwon HC. Feasibility and safety of the transradial approach for the intracoronary spasm provocation test. Catheter Cardiovasc Interv 2005; 65:240-6. [PMID: 15822071 DOI: 10.1002/ccd.20330] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
An angiography-based spasm provocation test is an accurate diagnostic test of coronary vasospastic angina, but is associated with high patient morbidity, mainly because of the femoral approach and the need for a temporary pacemaker. The purpose of this study was to investigate the safety and feasibility of a transradial ergonovine spasm provocation test. The test was performed prospectively in 174 consecutive patients who were under suspicion of coronary vasospasm at our institution from April 2002 to June 2003. Seventy-eight out of 174 procedures (45%) were performed in an outpatient department. The procedural success rate was 168/174 (96%). All failures were because of access failures, and no major complications were noted. Minor complications were observed in nine patients (severe bradycardia in three, hypotension in two, both in two, and nonsustained ventricular tachycardia in two). The incidence of complications was higher in patients showing prolonged spasm in the right coronary artery. No major local complication was noted other than rebleeding in the puncture site during hemostasis in one patient. The transradial spasm provocation test performed without using a temporary pacemaker may be feasible and safe, with a high success rate and low complication rate as well as low patient morbidity.
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Affiliation(s)
- Kyung Jin Lee
- Division of Cardiology, Department of Internal Medicine, Eulji University School of Medicine, Daejeon, South Korea
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Song JK, Park SW, Kang DH, Hong MK, Lee CW, Song JM, Kim JJ, Park SJ. Prognostic implication of ergonovine echocardiography in patients with near normal coronary angiogram or negative stress test for significant fixed stenosis. J Am Soc Echocardiogr 2002; 15:1346-52. [PMID: 12415227 DOI: 10.1067/mje.2002.125284] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The goal of this study was to assess the prognostic value of ergonovine echocardiography (Erg Echo) for diagnosis of coronary vasospasm (CVS) in patients without significant fixed coronary stenosis. MATERIAL AND METHODS Medical records of 650 patients who underwent Erg Echo were reviewed. Before Erg Echo, absence of significant fixed coronary stenosis was confirmed by invasive coronary angiography (CAG) in 316 patients (49%) or by noninvasive confirmation of negative treadmill or normal myocardial perfusion scan in 334 patients (51%). The cardiac events after Erg Echo were tabulated and these included cardiac death, myocardial infarction (MI), readmission due to intractable chest pain. RESULTS The average age was 54 +/- 10 years, with 223 women and 427 men. Erg Echo was positive in 237 patients (36%), for whom long-acting calcium channel blocker and nitrates were prescribed. During follow-up (46 +/- 23 months), cardiac events developed in 13% (30 of 237) of the positive Erg Echo group and 3% (14 of 413) of the negative Erg Echo group (P <.001). Incidence of cardiac death was higher in the positive Erg Echo group (3.4% vs 0.7%, P =.022). The 5-year survival rate (93% +/- 3% vs 99% +/- 1%, P =.013) and event-free survival rate (94% +/- 2% vs 77% +/- 6%, P <.001) were significantly lower in the positive Erg Echo group. Smoking (hazards ratio 6.3; 95% CI 1.7-23.5) and multivessel spasm (hazards ratio 37.2, 95% CI, 8.1 to 170.4) were independent factors associated with cardiac death and/or MI. CONCLUSION Erg Echo for noninvasive diagnosis of CVS in the differential diagnosis of chest pain provides useful prognostic information for patients without significant fixed coronary stenosis and can play a role as a cost-effective diagnostic strategy in these selected patients.
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Affiliation(s)
- Jae-Kwan Song
- Division of Cardiology, Asan Medical Center, University of Ulsan, College of Medicine, Poongnap-dong, Songpa-ku, Seoul, South Korea.
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Meisner JS, Shirani J, Alaeddini J, Frishman WH. Use of pharmaceuticals in noninvasive cardiovascular diagnosis. HEART DISEASE (HAGERSTOWN, MD.) 2002; 4:315-30. [PMID: 12350244 DOI: 10.1097/00132580-200209000-00008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
A number of pharmaceuticals are employed as diagnostic agents for cardiovascular diseases. Four groups of agents are reviewed here: 1) vasoactive substances employed as adjuncts to physical maneuvers in diagnosis of structural heart disease; 2) vasodilators used to produce heterogeneity of coronary flow; 3) sympathomimetic agents simulating the effects of exercise on the heart for the purpose of detection of coronary artery stenosis; and 4) ultrasonic contrast agents used to enhance myocardial imaging for the assessment of segmental wall motion. In the first group are amyl nitrate, a vasodilator, and methoxamine and phenylephrine, both vasopressors. The vasodilators of the second group are dipyridamole and adenosine. When combined with scintigraphic perfusion imaging or with echocardiographic assessment of segmental wall motion, these agents can detect single- or multiple-vessel coronary artery disease with sensitivity and specificity comparable to submaximal exercise. They are especially useful for preoperative risk assessment before noncardiac surgery. The sympathomimetic agents of the third group, dobutamine and arbutamine, increase myocardial contractility and heart rate, and dilate the peripheral vasculature. As with the vasodilators, when combined with nuclear or echocardiographic techniques they are equivalent to exercise in detection of coronary disease. They are especially useful in patients with bronchospastic disease and for assessment of myocardial viability. Agents from groups 2 and 3 have acceptable side-effect and safety profiles. The last group reviewed includes echocardiographic contrast agents that, in this investigative setting, are employed to enhance detection of segmental wall motion when used with agents from groups 2 and 3.
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Affiliation(s)
- Jay S Meisner
- Department of Medicine, Divisions of Cardiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA.
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Epureanu V, San Román JA, Vega JL, Fernández-Avilés F. [Acute pulmonary edema with normal coronary arteries: mechanism identification by ergonovine stress echocardiography]. Rev Esp Cardiol 2002; 55:775-7. [PMID: 12113708 DOI: 10.1016/s0300-8932(02)76699-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Coronary spasm is a constriction of the epicardial coronary arteries that produces myocardial ischemia. It is considered the main mechanism of the dynamic coronary artery stenosis. The standard method for diagnosing coronary spasm is the ergonovine test during diagnostic coronary angiography. Another test currently used is stress echocardiography with intravenous ergonovine injection. We present the case of a patient with angina, acute pulmonary edema and normal angiographic coronary arteries in which stress echocardiography with ergonovine demonstrated transient severe mitral regurgitation.
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Affiliation(s)
- Valeriu Epureanu
- Instituto de Ciencias del Corazón (ICICOR), Hospital Universitario, Valladolid, Spain
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Hirano Y, Ozasa Y, Yamamoto T, Nakagawa K, Uehara H, Yamada S, Ikawa H, Ishikawa K. Diagnosis of vasospastic angina by hyperventilation and cold-pressor stress echocardiography: comparison to I-MIBG myocardial scintigraphy. J Am Soc Echocardiogr 2002; 15:617-23. [PMID: 12050603 DOI: 10.1067/mje.2002.118033] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We assessed the usefulness of hyperventilation and cold-pressor stress echocardiography in the diagnosis of vasospastic angina compared with that of iodine-123 metaiodobenzylguanidine (123I-MIBG) myocardial scintigraphy. BACKGROUND Various noninvasive methods have been used to detect vasospastic angina, but they are not very sensitive in the diagnosis of vasospastic angina. 123I-MIBG images and stress echocardiography have recently been proposed as a useful tool for detecting vasospastic angina. METHOD Thirty patients (21 males and 9 females, mean age: 52 +/- 14 years) who complained of rest angina were enrolled for this study. The hyperventilation and cold-pressor stress echocardiography test consisted of hyperventilation for 6 minutes, followed by cold water pressor for 2 minutes under continuous electrocardiographic and echocardiographic monitoring. Left ventricular regional wall motion by echocardiogram was analyzed by using the 16-segment model, and wall motion ranging from normokinesis to dyskinesis was evaluated visually in each segment. Single-photon emission computed tomography images of 123I-MIBG myocardial scintigraphy were divided into 26 segments. Defect scores were established using the 4 grades. The echocardiographic criteria for coronary spasm was worsening wall motion and the scintigraphic criteria was defect score more than moderately reduced. Acetylcholine was selectively injected into the right coronary artery (20 microg and 50 microg) and left coronary artery (20 microg, 50 microg, and 100 microg). RESULTS Of 30 patients, 20 patients had coronary spasm on coronary angiography with an intracoronary injection of acetylcholine, whereas 10 patients showed no spasm. Multivessel spasms were observed in 15 patients. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of hyperventilation and cold-pressor stress echocardiography for diagnosing in patients with vasospastic angina were 90%, 90%, 95%, 82%, and 90%, respectively. However, those of 123I-MIBG myocardial scintigraphy for diagnosing in patients with vasospastic angina were 90%, 40%, 75%, 67%, and 73%, respectively. The specificity of hyperventilation and cold-pressor stress echocardiography was significantly higher than that of 123I-MIBG myocardial scintigraphy (P <.05). CONCLUSION The specificity of hyperventilation and cold-pressor stress echocardiography in diagnosing coronary spasm were higher than that shown by 201I-MIBG myocardial scintigraphy.
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Affiliation(s)
- Yutaka Hirano
- Department of Cardiology, Kinki University School of Medicine, Ohnohigashi Osakasayama, Japan.
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Candell-Riera J, Martín-Comín J, Escaned J, Peteiro J. [Physiologic evaluation of coronary circulation. Role of invasive and non invasive techniques]. Rev Esp Cardiol 2002; 55:271-91. [PMID: 11893319 DOI: 10.1016/s0300-8932(02)76596-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
For many years, the evaluation of the extent and severity of coronary artery disease has been mainly anatomical, carried out by coronary angiography. However, this technique has methodological limitations and interobserver variability is considerable. Quantification of coronary reserve with pressure guidewires and intracoronary Doppler now provides more precise physiologic evaluation of coronary circulation. Myocardial perfusion single proton emission computed tomography and echocardiography, combined with stress and/or pharmacological challenge testing, though they are only semiquantitative techniques, also offer appropriate complements to coronary angiography in the functional evaluation of coronary patients. The aim of this paper is to discuss the clinical value of these techniques.
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Pálinkás A, Picano E, Rodriguez O, Diordjevic-Dikic A, Landi P, Varga A, Ghelarducci B. Safety of ergot stress echocardiography for non-invasive detection of coronary vasospasm. Coron Artery Dis 2001; 12:649-54. [PMID: 11811330 DOI: 10.1097/00019501-200112000-00008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The safety of ergonovine/ergometrine stress testing for coronary vasospasm when performed outside the cardiac catheterization laboratory (cath lab) has been questioned vigorously. AIM To assess the tolerability and safety of ergonovine/ergometrine stress testing performed in the echocardiographic laboratory (echo lab). METHODS We retrospectively reviewed the data prospectively collected in the echo lab of the Institute of Clinical Physiology from 1 January 1985 to 1 June 2000, from 587 tests performed on 573 patients (either ergonovine or ergometrine stress echocardiography testing). By selection, all patients had a history of chest pain, consistent with vasospastic angina, negative exercise stress testing or stress echocardiography (with dipyridamole, dobutamine or exercise), and normal or near normal resting left ventricular function. Ergonovine or ergometrine maleate was injected up to a total cumulative dosage of 0.35 mg, under continuous 12-lead electrocardiographic and two-dimensional echocardiographic monitoring. RESULTS There were no deaths, myocardial infarctions, ventricular fibrillations or third degree AV blocks. One patient had non-sustained ventricular tachycardia associated with transient ST segment elevation 30 min after the test. Three patients had second degree AV block associated with a positive echocardiography test that was promptly reversed by nitrates administration. Transient regional myocardial dysfunction occurred in 79 patients (13%). Limiting ischaemia-independent side effects were present in 17 patients (3%): hypotension in one, arterial hypertension in five, non-sustained ventricular tachycardia in two and nausea or vomiting in ten. The test was well tolerated and echocardiograms were interpretable in 97% of the tests performed. CONCLUSION Pharmacological stress echocardiography with either ergonovine or ergometrine is well tolerated and can be performed with relatively low risk in the echo lab in properly selected patients in whom coronary vasospasm is suspected.
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Affiliation(s)
- A Pálinkás
- Institute of Clinical Physiology, Consiglio Nazionale Ricerche, Pisa, Italy
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Nedeljkovic MA, Ostojic M, Beleslin B, Nedeljkovic I, Marinkovic J, Babic R, Stankovic G, Stojkovic S, Saponjski J, Djordjevic-Dikic A, Stepanovic J, Petrasinovic Z, Vukcevic V, Nedeljkovic S, Kanjuh V. Efficiency of ergonovine echocardiography in detecting angiographically assessed coronary vasospasm. Am J Cardiol 2001; 88:1183-7. [PMID: 11703968 DOI: 10.1016/s0002-9149(01)02058-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- M A Nedeljkovic
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Belgrade, Yugoslavia
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