1
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Sueda S, Hayashi Y, Ono H, Okabe H, Sakaue T, Ikeda S. Lack of Class I Vasoreactivity Testing for Diagnosing Patients With Coronary Artery Spasm. Clin Cardiol 2024; 47:e70004. [PMID: 39192815 DOI: 10.1002/clc.70004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Accepted: 07/30/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Vasoreactivity testing, such as intracoronary acetylcholine (ACh) or ergometrine (EM), is defined as Class I for the diagnosis of patients with vasospastic angina (VSA) according to recommendations from the Coronary Vasomotion Disorders International Study (COVADIS) group and guidelines from the Japanese Circulation Society (JCS). HYPOTHESIS Although vasoreactivity testing is a clinically useful tool, it carries some risks and limitations in diagnosing coronary artery spasm. METHODS Previous reports on vasoreactivity testing for diagnosing the presence of coronary spasm are summarized from the perspective of Class I. RESULTS There are several problems such as reproducibility, underestimation, overestimation, and inconclusive/nonspecific results associated with daily spasm. Because provoked spasm caused by intracoronary ACh is not always similar to that caused by intracoronary EM, possibly due to different mediators, supplementary use of these vasoreactivity tests is necessary for cardiologists to diagnose VSA when a provoked spasm is not revealed by each vasoactive agent. CONCLUSIONS Cardiologists should understand the imperfection of these vasoreactivity tests when diagnosing patients with VSA.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Minami Matsuyama Hospital, Matsuyma City, Ehime, Japan
| | - Yutaka Hayashi
- Department of Cardiology, Minami Matsuyama Hospital, Matsuyma City, Ehime, Japan
| | - Hiroki Ono
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama, Ehime, Japan
| | - Hikaru Okabe
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama, Ehime, Japan
| | - Tomoki Sakaue
- Department of Cardiology, Ehime University Graduate School of Medicine, Touon-shi, Ehime, Japan
| | - Shuntaro Ikeda
- Department of Cardiology, Ehime University Graduate School of Medicine, Touon-shi, Ehime, Japan
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Rehan R, Beltrame J, Yong A. Insights into the invasive diagnostic challenges of coronary artery vasospasm - A systematic review. J Cardiol 2024; 83:8-16. [PMID: 37541429 DOI: 10.1016/j.jjcc.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/06/2023]
Abstract
Coronary provocation testing is an essential diagnostic procedure when evaluating vasospastic angina. Invasive methods using acetylcholine or ergonovine are considered the current gold standard. Despite efforts from global cardiovascular institutions, current protocols vary in dosage, administration time, and procedural approach. In addition, concerns over the specificity of findings and potential complications have limited routine uptake of this procedure in clinical practice. This systematic review evaluates current diagnostic protocols, focusing on invasive provocation testing. We included studies using intracoronary provocation testing with acetylcholine or ergonovine for the assessment of coronary artery vasospasm that detailed specific elements of the procedure (dosage, administration time, etc.) and included ≥50 patients. A total of 28 articles met strict inclusion criteria. Our review highlights the heterogeneity between current diagnostic protocols for invasive provocation testing. We believe standardization of a diagnostic protocol will encourage both current and future cardiologists to incorporate such procedures in the evaluation of variant angina.
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Affiliation(s)
- Rajan Rehan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Department of Cardiology, Concord Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - John Beltrame
- Discipline of Medicine, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, Adelaide, South Australia, Australia
| | - Andy Yong
- Department of Cardiology, Concord Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
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3
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Hokimoto S, Kaikita K, Yasuda S, Tsujita K, Ishihara M, Matoba T, Matsuzawa Y, Mitsutake Y, Mitani Y, Murohara T, Noda T, Node K, Noguchi T, Suzuki H, Takahashi J, Tanabe Y, Tanaka A, Tanaka N, Teragawa H, Yasu T, Yoshimura M, Asaumi Y, Godo S, Ikenaga H, Imanaka T, Ishibashi K, Ishii M, Ishihara T, Matsuura Y, Miura H, Nakano Y, Ogawa T, Shiroto T, Soejima H, Takagi R, Tanaka A, Tanaka A, Taruya A, Tsuda E, Wakabayashi K, Yokoi K, Minamino T, Nakagawa Y, Sueda S, Shimokawa H, Ogawa H. JCS/CVIT/JCC 2023 guideline focused update on diagnosis and treatment of vasospastic angina (coronary spastic angina) and coronary microvascular dysfunction. J Cardiol 2023; 82:293-341. [PMID: 37597878 DOI: 10.1016/j.jjcc.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2023]
Affiliation(s)
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Yasushi Matsuzawa
- Division of Cardiology, Yokohama City University Medical Center, Japan
| | - Yoshiaki Mitsutake
- Division of Cardiovascular Medicine, Kurume University School of Medicine, Japan
| | - Yoshihide Mitani
- Department of Pediatrics, Mie University Graduate School of Medicine, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Yasuhiko Tanabe
- Department of Cardiology, Niigata Prefectural Shibata Hospital, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Nobuhiro Tanaka
- Division of Cardiology, Tokyo Medical University Hachioji Medical Center, Japan
| | - Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroki Ikenaga
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Takahiro Imanaka
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | | | - Yunosuke Matsuura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Hiroyuki Miura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yasuhiro Nakano
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Takayuki Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | | | - Ryu Takagi
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Etsuko Tsuda
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Japan
| | - Kohei Wakabayashi
- Division of Cardiology, Cardiovascular Center, Showa University Koto-Toyosu Hospital, Japan
| | - Kensuke Yokoi
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Toru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Japan
| | - Shozo Sueda
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Japan
| | - Hiroaki Shimokawa
- Graduate School, International University of Health and Welfare, Japan
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Boerhout CKM, Beijk MAM, Damman P, Piek JJ, van de Hoef TP. Practical Approach for Angina and Non-Obstructive Coronary Arteries: A State-of-the-Art Review. Korean Circ J 2023; 53:519-534. [PMID: 37525496 PMCID: PMC10435829 DOI: 10.4070/kcj.2023.0109] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/19/2023] [Indexed: 08/02/2023] Open
Abstract
Anginal symptoms are frequently encountered in patients without the presence of significant obstructive coronary artery disease (CAD). It is increasingly recognized that vasomotor disorders, such as an abnormal vasodilatory capacity of the coronary microcirculation or coronary vasospasm, are the dominant pathophysiological substrate in these patients. Although the evidence with respect to angina in patients with non-obstructive coronary arteries is accumulating, the diagnosis and treatment of these patients remains challenging. In this review, we aimed to provide a comprehensive overview regarding the pathophysiological origins of angina with non-obstructive coronary arteries disorders and its diagnostic and therapeutic considerations. Hereby, we provide a practical approach for the management of patents with angina and non-obstructive CAD.
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Affiliation(s)
| | | | - Peter Damman
- Department of Cardiology, Radboud University Medica Centre, Nijmegen, The Netherlands
| | - Jan J Piek
- Heart Center, Amsterdam UMC, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- Division Heart and Lung, Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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5
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Hung MY, Hung MJ. Relationship between Inflammation and Vasospastic Angina. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020318. [PMID: 36837519 PMCID: PMC9960836 DOI: 10.3390/medicina59020318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/29/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
Coronary artery spasm (CAS) is a dynamic coronary stenosis causing vasospastic angina (VSA). However, VSA is a potentially lethal medical condition with multiple presentations, including sudden cardiac death. Despite investigations to explore its pathogenesis, no single mechanism has been found to explain the entire process of VSA occurrence. The roles of elevated local and systemic inflammation have been increasingly recognized in VSA. Treatment strategies to decrease local and systemic inflammation deserve further investigation.
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Affiliation(s)
- Ming-Yow Hung
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei 110, Taiwan
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
| | - Ming-Jui Hung
- Section of Cardiovascular Imaging, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Keelung, Chang Gung University College of Medicine, Taoyuan 333, Taiwan
- Correspondence:
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6
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Sueda S, Sakaue T. Sex-related differences in coronary vasomotor disorders: Comparisons between Western and Japanese populations. J Cardiol 2023; 81:161-167. [PMID: 35534347 DOI: 10.1016/j.jjcc.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/19/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
Sex-related differences in the prevalence of cardiac disorders have been elucidated beyond races. Angina/ischemia with nonobstructive coronary artery disease (AINOCA) is often observed in females. Coronary microvascular dysfunction (CMD) and coronary epicardial spasm (CES) are the principal cause of AINOCA. The clinical outcomes of Western patients with CMD were less satisfactory than expected, while the prognosis of Japanese patients with CES treated with medications including calcium channel blockers was favorable. However, the incidence and clinical features of coronary spasm endotypes were different between Western and Japanese populations. Furthermore, sex-related differences in the clinical manifestations and outcomes of patients with different spasm endotypes remain uncertain beyond race. In this article, we will review the sex differences in Japanese AINOCA patients with coronary vasomotor disorders, including CMD and CES, and compare them with those of Western patients.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama City, Ehime Prefecture, Japan.
| | - Tomoki Sakaue
- Department of Cardiology, Yawatahama City General Hospital, Yawatahama City, Ehime Prefecture, Japan
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7
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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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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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Assessment of coronary spasms with transluminal attenuation gradient in coronary computed tomography angiography. PLoS One 2022; 17:e0271189. [PMID: 35802711 PMCID: PMC9269916 DOI: 10.1371/journal.pone.0271189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 06/24/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose To evaluate the imaging features of coronary spasm, including transluminal attenuation gradient (TAG) on coronary computed tomography angiography (CCTA), in patients with vasospastic angina (VA). Methods A total of 43 patients with a high clinical likelihood of VA were included in the study. All the subjects underwent double CCTA acquisition: CCTA without a vasodilator (‘baseline CT’) and CCTA during continuous intravenous nitrate infusion (‘IV nitrate CT’). A catheterized ergonovine provocation test was used to determine true VA patients. Coronary spasm is classified into focal- and diffuse-types according to morphological differences. We measured TAG and contrast enhancement of the proximal ostium (ProxHU) of each coronary artery for both the baseline and IV nitrate CT. Results Twenty-four patients (55.8%) showed positive results of coronary vasospasm on the provocation test. Thirty-eight vessels showed coronary spasms (29.5%): Focal-type in nine vessels (24%), and diffuse-type in 29 (76%). In the baseline CT, LCX showed significantly lower (steeper) TAG in spasm(+) vessels than in spasm(-) vessels, while LAD and RCA showed no significant differences in TAG. The ProxHU of LAD showed significantly lower values in spasm(+) vessels than in spasm(-) vessels, while the other vessels did not show significant differences in ProxHU. For IV nitrate CT, there were no significant differences in either the TAG and ProxHU between spasm(+) and (-) vessels for all the three vessel types. In subgroup analysis for spasm(+) vessels, diffuse spasms showed significantly lower TAG than focal spasms, while the ProxHU did not differ between the two types of spasm. Conclusions A relatively large percentage of coronary spasms present as diffuse type, and the TAG values significantly differed according to the morphological type of the coronary spasm.
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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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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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12
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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13
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Niccoli G, Morrone D, De Rosa S, Montone RA, Polimeni A, Aimo A, Mancone M, Muscoli S, Pedrinelli R, Indolfi C. The central role of invasive functional coronary assessment for patients with ischemic heart disease. Int J Cardiol 2021; 331:17-25. [PMID: 33529656 DOI: 10.1016/j.ijcard.2021.01.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/05/2021] [Accepted: 01/15/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Giampaolo Niccoli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Medicine, University of Parma, Parma, Italy.
| | - Doralisa Morrone
- Division of Cardiology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Salvatore De Rosa
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Polimeni
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy
| | - Alberto Aimo
- Division of Cardiology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Massimo Mancone
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Saverio Muscoli
- Department of Medicine, 'Tor Vergata' University of Rome, Rome, Italy
| | - Roberto Pedrinelli
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy
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14
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Sueda S, Sakaue T. Coincidence between spontaneous and inducible coronary spasm: acetylcholine test is clinically valued for diagnosing coronary spasm. Heart Vessels 2021; 36:749-755. [PMID: 33389065 DOI: 10.1007/s00380-020-01748-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/27/2020] [Indexed: 12/20/2022]
Abstract
There is no report regarding the correlation between spontaneous documented coronary spasm and acetylcholine (ACh)-inducible spasm. We retrospectively analyzed the coincidence between angiographical spontaneous coronary spasm and ACh-inducible spasm in the same patients. We recruited 28 patients with 30 angiographical spontaneous coronary spasm in 6009 patients with diagnostic and follow-up coronary arteriography from Jan 1991 and Mar 2019 in the cardiac catheterization laboratory. We could perform intracoronary ACh testing in 19 patients with 20 vessels. ACh was injected in incremental dose of 20/50/100 μg into the left coronary artery and 20/50/80 μg into the right coronary artery. Positive spasm was defined as > 90% stenosis and ischemic ECG changes. Angiographical documented spontaneous coronary spasm was observed in 0.47% (28/6009) of patients with diagnostic and follow-up coronary angiography. Intracoronary administration of ACh reproduced 15 spontaneous coronary spasm and no provoked spasm was observed in the remaining 5 vessels due to the administration of nitroglycerine or under medications. Spasm-provoked sites by ACh tests and ACh-inducible spasm configurations were almost similar to spontaneous spasm. Coincidence of provoked spasm site (93.3% vs. 6.7%, p < 0.001) and spasm configuration (93.3% vs. 6.7%, p < 0.001) was markedly higher than discordance. Intracoronary ACh testing can reproduce spontaneous coronary artery spasm in 75% of vessels with almost similar sites and same morphological characteristics irrespective of the administration of nitroglycerine or vasodilators. ACh test is a reliable method to document coronary artery spasm in the clinic.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan.
| | - Tomoki Sakaue
- Department of Cardiology, Yawatahama City General Hospital, Yawatahama, Japan
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15
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Montone RA, Meucci MC, De Vita A, Lanza GA, Niccoli G. Coronary provocative tests in the catheterization laboratory: Pathophysiological bases, methodological considerations and clinical implications. Atherosclerosis 2020; 318:14-21. [PMID: 33360263 DOI: 10.1016/j.atherosclerosis.2020.12.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/13/2020] [Accepted: 12/10/2020] [Indexed: 12/17/2022]
Abstract
The paradigm for the management of patients presenting with angina and/or myocardial ischemia has been historically centered on the detection and treatment of obstructive coronary artery disease (CAD). However, in a considerable proportion (30-50%) of patients undergoing coronary angiography, obstructive CAD is excluded. Thus, functional mechanisms may be involved in determining myocardial ischemia and should be investigated. In particular, coronary vasomotor disorders both at epicardial and at microvascular level may play a crucial role, but a definitive diagnosis of these disorders can at times be difficult, given the transience of symptoms, and often requires the use of coronary provocative tests. Of importance, these tests may provide relevant information on the pathogenic mechanism of myocardial ischemia, allowing physicians to tailor the therapies of their patients. Furthermore, several studies underscored the important prognostic information deriving from the use of coronary provocative tests. Nevertheless, their use in clinical practice is currently limited and mainly restricted to specialized centers, with only a minority of patients receiving a benefit from this diagnostic approach. In this review, we explain the pathophysiological bases for the use of provocative tests, along with their clinical, prognostic and therapeutic implications.
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Affiliation(s)
- Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Maria Chiara Meucci
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio De Vita
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Gaetano A Lanza
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy; Division of Cardiology, Parma University Hospital, Parma, Italy
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16
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Role of acetylcholine spasm provocation test as a pathophysiological assessment in nonobstructive coronary artery disease. Cardiovasc Interv Ther 2020; 36:39-51. [PMID: 33108592 PMCID: PMC7829227 DOI: 10.1007/s12928-020-00720-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 12/21/2022]
Abstract
Coronary angiography (CAG) sometimes shows nonobstructive coronary arteries in patients with suspected angina or acute coronary syndrome (ACS). The high prevalence of nonobstructive coronary artery disease (CAD) in those patients has recently been reported not only in Japan but also in Western countries, and is clinically attracting attention. Coronary spasm is considered to be one of the leading causes of both suspected stable angina and ACS with nonobstructive coronary arteries. Coronary spasm could also be associated with left ventricular dysfunction leading to heart failure, which could be improved following the administration of calcium channel blockers. Because we rarely capture spontaneous attacks of coronary spasm with electrocardiograms or Holter recordings, an invasive diagnostic modality, acetylcholine (ACh) provocation test, can be useful in detecting coronary spasm during CAG. Furthermore, we can use the ACh-provocation test to identify high-risk patients with coronary spasm complicated with organic coronary stenosis, and then treat with intensive care. Nonobstructive CAD includes not only epicardial coronary spasm but also microvascular spasm or dysfunction that can be associated with recurrent anginal attacks and poor quality of life. ACh-provocation test could also be helpful for the assessment of microvascular spasm or dysfunction. We hope that cardiologists will increasingly perform ACh-provocation test to assess the pathophysiology of nonobstructive CAD.
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17
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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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18
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Sueda S. Pharmacological spasm provocation testing in 2500 patients: provoked spasm incidence, complications and cardiac events. Heart Vessels 2020; 35:1368-1377. [PMID: 32350639 DOI: 10.1007/s00380-020-01616-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/17/2020] [Indexed: 10/24/2022]
Abstract
Pharmacological spasm provocation tests such as acetylcholine (ACh) and ergonovine (ER) had been performed in the clinic. We retrospectively analyzed the incidence of provoked spasm, complications during testing and the cardiac events after these tests. From January 1991 and October 2018, we performed pharmacological spasm provocation tests in 2500 patients: 1810 ACh tests, 1232 ER tests, 542 both tests, and 310 ACh added after ER tests. ACh was injected in incremental doses of 20/50/100/200 μg into the LCA and 20/50/80 μg into the RCA. ER was administered as a total dose of 64 μg into the LCA and 40 μg into the RCA. When adding ACh after ER, the total dose was 50/80 μg into the RCA and 100/200 μg into the LCA. Positive spasm was defined as ≥ 90% stenosis and usual chest pain or ischemic ECG changes. Mean follow-up duration was 47.5 ± 29.9 months. Overall, provoked positive spasm was found in 1095 patients (43.8%). The incidence of positive provoked spasm during ACh testing was significantly higher than that during other tests (ACh: 48.7% vs. ER: 28.9%, Both: 24%, ACh added after ER: 33.5%, p < 0.001). Multiple spasms were remarkably more frequent during ACh testing compared with the other 3 types of testing (ACh: 28.2% vs. ER: 7.4%, Both: 4.1%, ACh added after ER: 13.2%, p < 0.001). No death or acute myocardial infarction was observed, while major complications during ACh testing were significantly more frequent than during ER testing. Readmission due to recurrent angina pectoris in spasm-positive patients was remarkably more frequent than in spasm-negative patients. The incidence of sudden cardiac death, ventricular fibrillation, and acute coronary syndrome were not different between the spasm-positive and spasm-negative groups during the follow-up periods. We could perform all spasm provocation tests without any irreversible complications. All sequential spasm provocation tests were useful for documenting coronary spasm.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan.
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19
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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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20
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Benamer H, Saighi Bouaouina M, Masri A, Sarkis G, El Beze N, Millien V. [Vasospastic angina: An under-diagnosed pathology]. Ann Cardiol Angeiol (Paris) 2019; 68:341-346. [PMID: 31542201 DOI: 10.1016/j.ancard.2019.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 08/28/2019] [Indexed: 12/31/2022]
Abstract
The clinical and physiopathological clinical entity known as spastic angina or variant angina has been long documented. It remains, however, an under-estimated condition, which is insufficiently diagnosed and explored. This pathology is associated with severe complications such as heart rhythm disorders, which may potentially result in ventricular fibrillation and cause sudden death. In Japan, this condition occurs more frequently and is better documented. Stimulation tests are also carried out more often and have a higher positivity rate than in France where vasospastic angina is less frequently reported and where provocation tests are associated with negative results and are, consequently, performed less often. In order to improve the detection of this pathology, its potential presence should be explored in patients with rest angina who experience chest pain in the second half of the night and also in instances of acute coronary syndrome with sudden death and no angiographically visible coronary artery disease. The diagnosis should be confirmed by means of ergonovine provocation tests. In order to enhance the sensitivity of these tests without increasing the risk of complications, injection of ergonovine should be preferably carried out via the intracoronary route. By increasing the frequency and sensitivity of these tests, this pathology, which responds well to medical treatment in many cases, could be amenable to therapeutic management as any other form of coronary artery disease.
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Affiliation(s)
- H Benamer
- Groupe Ramsay générale de santé, Institut Jacques-Cartier, 6, avenue du Noyer-Lambert, 91300 Massy, France; ICVGVM la Roseraie, 120, avenue de la République, 93300 Aubervilliers, France; Hôpital Foch, 40, rue Worth, 92150 Suresnes, France.
| | - M Saighi Bouaouina
- Groupe Ramsay générale de santé, Institut Jacques-Cartier, 6, avenue du Noyer-Lambert, 91300 Massy, France; ICVGVM la Roseraie, 120, avenue de la République, 93300 Aubervilliers, France; Hôpital Foch, 40, rue Worth, 92150 Suresnes, France
| | - A Masri
- ICVGVM la Roseraie, 120, avenue de la République, 93300 Aubervilliers, France; Hôpital Foch, 40, rue Worth, 92150 Suresnes, France
| | - G Sarkis
- ICVGVM la Roseraie, 120, avenue de la République, 93300 Aubervilliers, France; Hôpital Foch, 40, rue Worth, 92150 Suresnes, France
| | - N El Beze
- Hôpital Foch, 40, rue Worth, 92150 Suresnes, France
| | - V Millien
- Centre hospitalier Saint-Quentin, 1, rue Michel de l'Hôpital, 02100 Saint-Quentin, France
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21
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[Coronary spasm a diagnostic and therapeutic challenge]. Presse Med 2018; 47:798-803. [PMID: 30245142 DOI: 10.1016/j.lpm.2018.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/05/2018] [Accepted: 08/07/2018] [Indexed: 12/15/2022] Open
Abstract
Vasospastic angina is a clinical and physio-pathological entity, which has been documented for many years, but its diagnosis is under-estimated despite the fact that though inadequately considered and investigated. This condition is potentially serious and can sometimes trigger severe arrhythmia resulting in ventricular fibrillation and sudden death. This pathology has a higher incidence in Asia, where it is, therefore, better documented with provocative testing being carried out more frequently, while in France, these tests are not sufficiently performed probably due to the fact that they often produce negative findings. Provocative tests with Ergonovine injection should be performed via intra-coronary to improve its sensibility. Should this test become more sensitive and more routinely performed, this condition, which often responds well to medical treatment, could regain appropriate recognition as a coronary disease.
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22
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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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Jin CD, Kim MH, Kang EJ, Cho YR, Park TH, Lee KN, Serebruany V. Assessing Vessel Tone during Coronary Artery Spasm by Dual-Acquisition Multidetector Computed Tomography Angiography. Cardiology 2017; 139:25-32. [PMID: 29166637 DOI: 10.1159/000478926] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 06/21/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Diminished vascular tone is an established biomarker of heart damage. Little is known about the extent of coronary vessel tone (CVT) with spasm as assessed by dual-acquisition multidetector computed tomography angiography (MCTA) in patients with vasospastic angina (VSA). OBJECTIVE We evaluated the CVT modulated by intravenous nitrate injection (INI) using MCTA imaging in VSA patients. METHODS Twenty-one VSA patients (60 ± 9 years; 76% males) who underwent initial MCTA (without morning vasodilation), followed by an intracoronary ergonovine provocation test were included. Within 3 days after the initial MCTA patients received INI followed by 28-vessel segment spasm analyzed by MCTA 3D software, applying the following formula as the definition of CVT index (CVTI): (CSAIV nitrate - CSAinitial/CSAIV nitrate) ×100 %, where CSA is the cross-sectional area. RESULTS Compared to the initial MCTA measures, the INI provocation resulted in the significant increase of average diameter and CSA at the spasm site (2.60 mm [2.11-3.16] vs. 1.42 mm [1.13-2.13]; 5.37 mm2 [3.67-7.54] vs. 1.62 mm2 [1.02-3.02]; p < 0.001). The CVTI at the spastic segments was higher than at the proximal reference segments (41.0% [21.8-52.3] vs. 18.8% [5.9-26.6] for CVTI diameter; 65.1% [38.6-77.0] vs. 33.9% [5.2-48.1] for CVTI CSA, respectively). To predict VSA, the cut-off value for CVTI diameter was 38.6% (AUC 0.777; 95% CI 0.653-0.901) and 62.5% (AUC 0.779; 95% CI 0.657-0.902) for CVTI CSA in a receiver-operating characteristic curve analysis, with 57.1% sensitivity and 92.9% specificity. CONCLUSIONS This novel imaging technique for assessing CVT by dual-acquisition MCTA after applying INI provocation is suitable for the detection of coronary artery spasm in patients with VSA.
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Affiliation(s)
- Cai De Jin
- Department of Cardiology, Nanjing Medical University Affiliated Wuxi Second Hospital, Wuxi, PR China
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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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Sueda S, Kohno H. Relationships between more than 90% coronary luminal narrowing induced by ergonovine provocation test and ECG ischemic change as well as chest symptoms. Heart Vessels 2017; 33:95-101. [PMID: 28808762 DOI: 10.1007/s00380-017-1035-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 08/09/2017] [Indexed: 01/27/2023]
Abstract
In the clinic, patients with ≥90% luminal narrowing during ergonovine (ER) testing had variable response. We investigated ischemic findings and chest symptoms in patients with ≥90% luminal narrowing when performing ER tests, retrospectively. We performed 1210 ER tests over 26 years (1991-2016). We analyzed chest symptoms and positive ischemic ECG changes during ER tests. More than 90% luminal narrowing was found in 352 patients (29.1%) including 211 patients in the right coronary artery (RCA) and 217 patients in the left coronary artery (LCA). Chest symptom was observed in 290 patients (82.4%) including 162 patients in the RCA and 179 patients in the LCA. ST elevation was found in 154 patients including 98 in the RCA and 73 patients in the LCA, while ST depression was recognized in 81 patients including 38 patients in the RCA and 62 patients in the LCA. Two-third of patients with ≥90% luminal narrowing had significant ischemic ECG changes, whereas 60.5% of patients with ≥90% luminal narrowing complained usual chest pain accompanied with significant ischemic ECG changes. Unusual chest symptom was complained in 7.1% of patients with ≥90% luminal narrowing. Neither chest symptom nor ECG changes was found in 48 patients (13.6%) with ≥90% luminal narrowing. We should understand some limitation to diagnose positive coronary spasm during ER tests.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Hongo 3 Chome 1-1, Niihama, Ehime Prefecture, 792-0042, Japan.
| | - Hiroaki Kohno
- Department of Cardiology, Tsukazaki Hospital, Himeji, Japan
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26
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Efe SC, Demirci K, Ozturk S, Gurbuz AS, Poci N, Kilicgedik A, Guler A, Yilmaz MF, İzgi IA, Kirma C. Serum endocan levels in patients with cardiac syndrome X. Herz 2017; 43:359-363. [PMID: 28589439 DOI: 10.1007/s00059-017-4580-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/30/2017] [Accepted: 05/10/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Endocan is a recently introduced marker of endothelial dysfunction and is also associated with inflammation and atherosclerosis. To date, the relationship between cardiac syndrome X (CSX) and endocan has not been studied. The objective of this study was to compare the serum endocan levels of patients with CSX with those of control subjects. PATIENTS AND METHODS In this study, 50 patients were included in the CSX group and 28 patients in the control group. Patients with pathological conditions that could potentially influence endothelial functions were excluded. Endocan serum concentrations were measured using an enzyme-linked immunosorbent assay. RESULTS The mean endocan level of the CSX group was significantly higher than that of the control group (3051.3 ± 1900.5 ng/l vs. 2088.1 ± 522.2 ng/l; p = 0.002). There was no difference between the two groups in terms of age, gender, hypertension, diabetes mellitus, dyslipidemia, and smoking status. In receiver operating characteristic (ROC) curve analysis, endocan levels greater than 2072 ng/l had a 72% sensitivity and 54% specificity (p = 0.002) for accurately predicting a diagnosis of CSX. CONCLUSION The results of this study suggest that patients with CSX have higher endocan levels. Therefore, endocan may be valuable in helping uncover the underlying pathogenesis of CSX.
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Affiliation(s)
- S C Efe
- Department of Cardiology, Agrı State Hospital, Fırat mahallesi, 00004, Agrı, Turkey.
| | - K Demirci
- Department of Cardiology, Goztepe Research and Education Hospital, Istanbul, Turkey
| | - S Ozturk
- Department of Cardiology, Haseki Training and Education Hospital, Istanbul, Turkey
| | - A S Gurbuz
- Department of Cardiology, Eskisehir State Hospital, Eskisehir, Turkey
| | - N Poci
- Department of Cardiology, Herz-Zentrum Bodensee Konstanz, Konstanz, Germany
| | - A Kilicgedik
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - A Guler
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - M F Yilmaz
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - I A İzgi
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - C Kirma
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
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Sueda S, Kohno H. Differential Incidence and Morphology of Spasm According to Coronary Arterial Location by Intracoronary Ergonovine Spasm Provocation Testing. Circ J 2017; 81:831-836. [PMID: 28331112 DOI: 10.1253/circj.cj-16-1046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND We reported less provoked spasm in the left circumflex artery (LCX) by acetylcholine testing compared with the left anterior descending artery (LAD) and right coronary artery (RCA), so we investigated the clinical characteristics of provoked spasm in the LCX by ergonovine (ER) testing.Methods and Results:We retrospectively analyzed 1,185 consecutive cases of intracoronary ER testing during 25 years. Maximal ER dose was 64 μg into the left coronary artery (LCA) and 40 μg into the RCA. Positive spasm was defined as a transient ≥90% narrowing and usual chest symptoms or ischemic ECG changes. Positive provoked spasm was recognized in 347 patients (29.3%), including 207 RCA spasms, 166 LAD spasms, and 79 LCX spasms. Spasm was provoked in the LCX significantly less than in the other vessels (P<0.001). LCX-provoked spasm was obtained in 79 patients consisting of 16 patients (20.3%) with triple-vessel spasm, 38 patients (48.1%) with double-vessel spasm and 25 patients (31.6%) with single-vessel spasm. Less than 70% patients with LCX-provoked spasm had multiple spasms, whereas approximately 60% patients had single-vessel spasm in the RCA (64.3%) or LAD (59.6%). In 25 patients with LCX single-vessel spasm, 18 patients (72.0%) had a focal spasm. CONCLUSIONS Under maximal ER dose of 64 μg into the LCA, LCX-provoked spasm occurred significantly less than spasm in the other vessels and less than 70% patients had multiple spasms.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Niihama Prefectural Hospital
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28
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Effects of neuropeptide Y on coronary artery vasomotion in patients with microvascular angina. Int J Cardiol 2017; 238:123-127. [PMID: 28476516 DOI: 10.1016/j.ijcard.2017.03.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 03/06/2017] [Accepted: 03/08/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with microvascular angina (exertional angina, positive exercise tests and normal coronary arteriograms) usually have a reduced coronary blood flow reserve. Neuropeptide Y (NPY) is a potent endogenous vasoconstrictor involved in modulation of coronary vasomotor tone and may play a role in microvascular angina. METHODS We compared the effects of NPY (0.2-1.0pmol/kg, intracoronary) on the vasomotor response of proximal and distal segments of the coronary arteries in 7 patients with microvascular angina, 9 with chronic stable angina, and 9 control individuals. The coronary response to the administration of ergonovine was also assessed in 9 other patients with microvascular angina. Computerized coronary artery diameter measurements were carried out before (baseline) and after the administration of the vasoactive agents. RESULTS Mean baseline coronary lumen diameters were similar in control, microvascular angina, and coronary artery disease patients. NPY constricted proximal coronary segments by 8±2%, 5±2% and 6±3% and distal segments by 14±2%, 11±2% and 10±2% in control, microvascular angina, and coronary artery disease patients, respectively (p=NS between groups). In patients with microvascular angina, ergonovine constricted proximal coronary segments by 7±1.5% and distal segments by 12.5±3% (p=NS vs. NPY). During NPY administration four microvascular angina patients developed chest pain, ST segment depression, and a marked lengthening of the contrast medium run off, in the absence of epicardial coronary artery spasm. Control individuals and coronary artery disease patients did not experience chest pain, ST segment shifts, or lengthening of the run off during NPY administration. Ergonovine administration caused chest pain and lengthening of the contrast run-off, in the absence of epicardial coronary artery spasm, in one microvascular angina patient. CONCLUSIONS Exogenous NPY causes mild epicardial coronary artery constriction which is similar in patients with non-cardiac chest pain, microvascular angina and coronary artery disease. Myocardial ischemia and marked lengthening of the contrast run off in response to NPY occurred in microvascular angina patients but not in control or coronary artery disease patients. An abnormal constrictor response to NPY at the microcirculation level could be the mechanism underlying the ischemic manifestations observed in patients with microvascular angina. CONDENSED ABSTRACT (TABLE OF CONTENTS) The vasomotor response of proximal and distal coronary artery segments was studied in twenty five patients: 7 microvascular angina, 9 chronic stable angina, and 9 control subjects. Computerized measurements of coronary diameters were carried out before and after the intracoronary administration of neuropeptide Y (NPY) and ergonovine. Constriction of epicardial arteries in response to NPY was mild and not significantly different in control, microvascular angina and coronary artery disease patients. Ergonovine-induced epicardial coronary artery constriction was similar to that of NPY. However, NPY caused transient myocardial ischemia in patients with microvascular angina (probably through constriction of the small intramyocardial vessels), but not in control subjects or coronary artery disease patients.
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Sueda S, Kohno H, Ochi T, Uraoka T, Tsunemitsu K. Overview of the pharmacological spasm provocation test: Comparisons between acetylcholine and ergonovine. J Cardiol 2016; 69:57-65. [PMID: 27856130 DOI: 10.1016/j.jjcc.2016.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/15/2016] [Accepted: 09/23/2016] [Indexed: 12/11/2022]
Abstract
The spasm provocation tests of ergonovine and acetylcholine have been employed in the cardiac catheterization laboratory. Ergonovine acts through the serotogenic receptors, while acetylcholine acts through the muscarinic cholinergic receptors. Different mediators may have the potential to cause different coronary responses. However, there are few reports concerning the coronary response between ergonovine and acetylcholine in the same patients. Acetylcholine is supersensitive for females; spasm provoked by ergonovine is focal and proximal, whereas provoked spasm by acetylcholine is diffuse and distal. We should use both tests as supplementary in the clinic because ergonovine and acetylcholine have self-limitations to induce coronary spasms during daily life. The maximal pharmacological doses, administration methods, and the angiographical positive definition are remarkably different for each institution in the world. We recommend the pharmacological spasm provocation tests as Class I in the guidelines in patients with vasospastic angina throughout the world.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Ehime, Japan.
| | - Hiroaki Kohno
- Department of Cardiology, Tsukazaki Hospital, Himeji, Hyogo, Japan
| | - Takaaki Ochi
- Department of Cardiology, Ochi Clinic, Iyogun Masaki Chou, Ehime, Japan
| | - Tadao Uraoka
- Department of Cardiology, Uraoka Clinic, Ozu, Ehime, Japan
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Hung MJ, Wang CH, Cherng WJ. Provocation of Coronary Vasospastic Angina Using an Isoproterenol Head-up Tilt Test. Angiology 2016; 55:271-80. [PMID: 15156260 DOI: 10.1177/000331970405500306] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The goals of this study were to determine the value of the isoproterenol (ISO) head-up tilt (HUT) test in detecting coronary vasospastic angina and to investigate the possible mechanism responsible for coronary artery spasm. The ISO + HUT test was performed in 16 patients with coronary artery spasm documented by the intracoronary ergonovine provocation test. Patients’ blood pressure and heart rate were measured at baseline, during the ISO + HUT (phase I), and during HUT after discontinuation of ISO (phase II). Patients were categorized as test-positive if they developed angina with ST-segment elevation during testing. Eight patients (50%) were test-positive (5 in phase I and 3 in phase II). Between the test-positive and test-negative groups, no significant differences were noted in the changes in blood pressure throughout the test. However, there were significant differences in the changes in heart rate from supine to 2 minutes after HUT under ISO infusion (-17 ±22 vs 11 ±25 beats/minute; p=0.035). In those patients with a positive result in the phase I stage, the heart rate decreased initially after tilt-up, and then significantly increased later (from 85 ±16 to 110 ±27 beats/minute; p=0.043), when coronary vasospasm occurred. In those patients with a positive result in the phase II stage, coronary vasospasm occurred immediately after HUT, when there was an insignificant transient increase in heart rate from the supine to the HUT position (from 85 ±12 to 92 ±11 beats/minute; p=0.109). The ISO + HUT test can provoke coronary vasospasm with ST-segment elevation in 50% of the patients with coronary artery spasm, when combined with an extensional protocol of HUT after discontinuation of ISO. This study suggests that the induction of coronary artery spasm during HUT testing is associated with a rapid elevation of sympathetic activity during augmented parasympathetic activity.
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Affiliation(s)
- Ming-Jui Hung
- Cardiology Section, Department of Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
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31
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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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Sueda S, Kohno H. Overview of complications during pharmacological spasm provocation tests. J Cardiol 2016; 68:1-6. [PMID: 27234219 DOI: 10.1016/j.jjcc.2016.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/01/2016] [Accepted: 03/04/2016] [Indexed: 12/13/2022]
Abstract
Pharmacological spasm provocation tests are invasive methods and we always have the potential to encounter complications when performing these tests. In 1980, Buxton et al. reported three deaths when they performed intravenous ergonovine testing. However, we now employ the intracoronary ergonovine test instead of the intravenous injection of ergonovine from a safety procedure point of view. Past serious major complications of intravenous ergonovine tests, intracoronary ergonovine tests, and intracoronary acetylcholine tests were 0.31% (26/8419), 0.51% (11/2173), and 0.95% (148/15,527), respectively. Selective intracoronary testing had the serious major complications in 0.89% of patients including just one death (0.006%) and two acute myocardial infarctions (0.01%). Selective spasm provocation tests had no additional risks compared with performing diagnostic coronary angiography alone. In the Western countries, the pharmacological spasm provocation tests are not familiar in the clinic except for some specialized institutions. We need international clinical studies using the same protocol of spasm provocation tests to compare the frequency, clinical features, and prognosis of acetylcholine- or ergonovine-provoked coronary spasm between Western and Asian countries. And we hope that Western guidelines give spasm provocation testing a class I indication similar to Japanese Circulation Society guidelines because coronary artery spasm may have fewer racial differences and borders.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Ehime, Japan.
| | - Hiroaki Kohno
- Department of Cardiology, Tsukazaki Hospital, Hyogo, Japan
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Abstract
OBJECTIVE We examined the clinical usefulness of sequential spasm provocation tests as follows: first, acetylcholine (ACh) test, second, ergonovine (ER) test, and finally, the ACh test following the ER test. PATIENTS AND METHODS We performed the ACh and ER tests in 461 patients (294 men, 64.4±11.3 years of age) during a 23-year period. In addition, we administered an intracoronary injection of ACh after the ER tests in 240 patients. First, ACh [right coronary artery (RCA): 20/50/(80) μg, left coronary artery (LCA): 20/50/100/(200) μg] was administered incrementally over 20 s. Second, ER (RCA: 40 μg, LCA: 64 μg) was administered over 2-4 min. If a provoked spasm did not occur, we administered an intracoronary injection of ACh (50/80 μg into the RCA and 100/200 μg into the LCA) just after the ER tests. A positive spasm was defined as more than 99% transient luminal narrowing. RESULTS A positive spasm was observed in 221 (47.9%) patients including 181 ACh-positive (39.3%) and 119 ER-positive (25.8%) patients by the ACh or ER tests. In the 240 patients with a negative spasm in the ACh and ER tests, 48 (10.4%) patients developed provoked spasms on adding ACh after the ER test. The distributions of various cardiac disorders and provoked spasm vessels were similar among the three positive groups. Focal spasm was frequently observed in the ER-positive group, whereas diffuse spasm was frequently obtained in the ACh-positive group and by adding ACh after ER in the positive group. No major complications were recognized during the sequential spasm provocation tests. CONCLUSION Sequential spasm provocation tests might overcome a limitation of standard spasm provocation tests.
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Sueda S, Kohno H, Ochi T, Uraoka T. Overview of the Acetylcholine Spasm Provocation Test. Clin Cardiol 2015; 38:430-8. [PMID: 26175183 DOI: 10.1002/clc.22403] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 02/09/2015] [Accepted: 02/11/2015] [Indexed: 12/16/2022] Open
Abstract
The acetylcholine (ACh) spasm provocation test proposed by Yasue, Okumura et al more than a quarter-century ago has become a popular method for induction of coronary spasm. This test is safe and has a low rate of complications. However, it may be limited in its ability to document attacks in daily life because previously it was the gold-standard method for diagnosing active variant angina. There may be some clinical issues to modify for the next generation of cardiologists. A maximal ACh dose of 50/100 µg in the right coronary artery/left coronary artery is recommended in the Japanese Circulation Society guidelines. We often experienced the usefulness of a maximal ACh dose of 80/200 µg for the induction of coronary spasm in some cases with low or moderate disease activity. It may be necessary to reconsider the maximal ACh dose as a modified method for today's real-world clinical practice. In young patients with rest angina, intracoronary injection of ACh is less sensitive for diagnosis; in these cases, we recommend performing sequential spasm provocation tests. Especially in female patients, to document coronary artery spasm we recommend performing ACh tests first, instead of ergonovine tests, due to the supersensitivity of ACh. We also recommend supplementary use of ACh and ergonovine. This review summarizes our experiences with the ACh spasm provocation test over a period of 24 years. We have found it to be a reliable and useful method for contributing a variety of clinical information and recommend it to the next generation of cardiologists.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Ehime, Japan
| | - Hiroaki Kohno
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Ehime, Japan
| | - Takaaki Ochi
- Department of Cardiology, Ochi Clinic, Ehime, Japan
| | - Tadao Uraoka
- Department of Cardiology, Uraoka Clinic, Ehime, Japan
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Park JJ, Park SJ, Choi DJ. Microvascular angina: angina that predominantly affects women. Korean J Intern Med 2015; 30:140-7. [PMID: 25750553 PMCID: PMC4351318 DOI: 10.3904/kjim.2015.30.2.140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 02/07/2015] [Indexed: 01/12/2023] Open
Abstract
In women receiving evaluation for suspected ischemic symptoms, a "normal" diagnosis is five times more common than it is in men. These women are often labeled as having cardiac syndrome X, also known as microvascular angina (MVA). MVA is defined as angina pectoris caused by abnormalities of the small coronary arteries, and is characterized by effort chest pain and evidence of myocardial ischemia with a non-invasive stress test, although the coronary arteries can appear normal or near normal by angiography. MVA patients are often neglected due to the assumption of a good prognosis. However, MVA has important prognostic implications and a proper diagnosis is necessary in order to relieve the patients' symptoms and improve clinical outcomes. The coronary microvasculature cannot be directly imaged using coronary angiography, due to the small diameter of the vessels; therefore, the coronary microvascular must be assessed functionally. Treatment of MVA initially includes standard anti-ischemic drugs (β-blockers, calcium antagonists, and nitrates), although control of symptoms is often insufficient. In this review, we discuss the pathophysiology, diagnosis, and treatment of MVA.
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Affiliation(s)
- Jin Joo Park
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Ju Choi
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Seoul National University College of Medicine, Seoul, Korea
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Niccoli G, Scalone G, Crea F. Coronary Functional Tests in the Catheterization Laboratory – Pathophysiological and Clinical Relevance –. Circ J 2015; 79:676-84. [DOI: 10.1253/circj.cj-15-0201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | | | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart
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Sueda S, Miyoshi T, Sasaki Y, Sakaue T, Habara H, Kohno H. Gender differences in sensitivity of acetylcholine and ergonovine to coronary spasm provocation test. Heart Vessels 2014; 31:322-9. [PMID: 25539623 DOI: 10.1007/s00380-014-0614-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 12/01/2014] [Indexed: 12/13/2022]
Abstract
We examined the sex difference concerning the coronary artery response between ACh and ER in this study. We already reported the difference of coronary response between acetylcholine (ACh) and ergonovine (ER). We performed both ACh and ER tests of 461 patients (male 294 patients, female 167 patients, mean age 64.4 ± 11.3 years) during 23 years. Positive coronary spasm was defined as >99 % transient luminal narrowing with usual chest pain and/or ischemic ECG changes. Firstly, ACh was administered in incremental doses of 20/50/(80) μg into the RCA and 20/50/100/(200) μg into the LCA over 20 s. Secondly, ER was administered in a total dose of 40 μg into the RCA and of 64 μg into the LCA over 2-4 min. Intracoronary injection of ACh and ER provoked spasm in 221 patients consisting of 160 male patients and 61 female patients. In female patients, the spasm provoked by ACh was almost perfect except in two patients (59 patients, 96.7 %), while ER provoked spasm in only 20 patients (32.8 %). In male patients, provoked spasm by ACh (129 patients, 80.6 %) was significantly higher than ER (97 patients, 60.6 %). As a spasm provocation test, ACh is more sensitive than ER in both sexes and especially in females. We may select two pharmacological agents by sex differences to provoke coronary artery spasm in the cardiac catheterization laboratory in the future.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan.
| | - Toru Miyoshi
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Ysuhiro Sasaki
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Tomoki Sakaue
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Hirokazu Habara
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Hiroaki Kohno
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
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Sueda S, Miyoshi T, Sasaki Y, Sakaue T, Habara H, Kohno H. Safety and optimal protocol of provocation test for diagnosis of multivessel coronary spasm. Heart Vessels 2014; 31:137-42. [PMID: 25366987 DOI: 10.1007/s00380-014-0591-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/03/2014] [Indexed: 01/01/2023]
Abstract
We examined the safety of acetylcholine (ACh) and ergonovine (ER) tests retrospectively and investigated the optimal protocol of provocation test for diagnosis of multivessel coronary spasm. We performed 1546 ACh tests and 1114 ER tests during 23 years. ACh was injected in incremental doses of 20/50/80 μg into the right coronary artery (RCA) and of 20/50/100/200 μg into the left coronary artery (LCA) over 20 s. ER was administered in total doses of 40 μg into the RCA and of 64 μg into the LCA over 2-4 min. When a coronary spasm was induced and did not resolve spontaneously within 3 min after the completion of ACh/ER injection, or when hemodynamic instability due to coronary spasms occurred, 2.5-5.0 mg of nitrate was administered into the responsible vessel. To relive provoked spasm, it is necessary to administer nitrate in 31 cases by ACh and in 76 cases by ER (2.0 vs. 6.8 %, p < 0.01) before another vessel attempts. Multivessel spasms were often observed in LCA testing than in RCA testing on both agents [ACh: 78.6 % (11/14) vs. 11.8 % (2/17), p < 0.001, ER: 37.8 % (14/37) vs. 20.5 % (8/39), ns]. Even after the administration of nitrates, positive coronary spasm was obtained in 21.1 % by ACh and 52.9 % by ER tests on another coronary artery. No irreversible complications were recognized on both tests. We should firstly perform spasm provocation tests in the LCA and we may be able to diagnose another vessel spasm by performing the complete spasm provocation tests after the administration of nitrates to relieve provoked spasm in the first attempt.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan.
| | - Toru Miyoshi
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Yasuhiro Sasaki
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Tomoki Sakaue
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Hirokazu Habara
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
| | - Hiroaki Kohno
- Department of Cardiology, Ehime Niihama Prefectural Hospital, Hongou 3 choume 1-1, Niihama, Ehime, 792-0042, Japan
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Angina Pectoris and Myocardial Ischemia in the Absence of Obstructive Coronary Artery Disease: Practical Considerations for Diagnostic Tests. JACC Cardiovasc Interv 2014; 7:453-63. [DOI: 10.1016/j.jcin.2014.01.157] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 01/03/2014] [Accepted: 01/16/2014] [Indexed: 01/09/2023]
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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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Abstract
Coronary artery spasm (CAS), an intense vasoconstriction of coronary arteries that causes total or subtotal vessel occlusion, plays an important role in myocardial ischemic syndromes including stable and unstable angina, acute myocardial infarction, and sudden cardiac death. Coronary angiography and provocative testing usually is required to establish a definitive diagnosis. While the mechanisms underlying the development of CAS are still poorly understood, CAS appears to be a multifactorial disease but is not associated with the traditional risk factors for coronary artery disease. The diagnosis of CAS has important therapeutic implications, as calcium antagonists, not β-blockers, are the cornerstone of medical treatment. The prognosis is generally considered benign; however, recurrent episodes of angina are frequently observed. We provide a review of the literature and summarize the current state of knowledge regarding the pathogenesis of CAS.
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Affiliation(s)
- Ming-Jui Hung
- 1. Department of Cardiology, Chang Gung Memorial Hospital, Keelung, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Patrick Hu
- 2. International Cardiovascular Institute, Las Vegas, Nevada, USA; ; 3. Department of Cardiology, Riverside Medical Clinic, Riverside, California, USA
| | - Ming-Yow Hung
- 4. Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; ; 5. Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; ; 6. Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Song BG, Oh JH, Kim HJ, Kim SH, Chung SM, Lee M, Kang GH, Park YH, Chun WJ. Chronobiological variation in the occurrence of Tako-tsubo cardiomyopathy: experiences of two tertiary cardiovascular centers. Heart Lung 2012; 42:40-7. [PMID: 23083536 DOI: 10.1016/j.hrtlng.2012.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 09/24/2012] [Accepted: 09/26/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND There have been few data to review and analyze the temporal preference of the onset of Tako-tsubo cardiomyopathy (TTC). Aim of this study was to investigate chronobiological variations in the occurrence of TTC and changes of these variations according to age and gender. METHODS One hundred and thirty-seven patients were enrolled from our TTC registry database from January 2004 to December 2010 in Korea. RESULTS The median age of the entire study population was 59 years (inter-quartile range 53-72 years). The majority of patients were women (n = 101, 74%). The onset of TTC differed as a function of season (P = .001), with the peak in July and the nadir in March. Events were most frequent in summer (n = 53%, 38.7%) and least so in winter (n = 26, 19%, chi-square = 13.92, P = .003). TTC was most frequent in the morning (n = 56, 40.9%) and least so at night (n = 22, 16.1%, chi-square = 21.98, P = .001). Also, TTC was most frequent on Monday (n = 34, 24.8%) and least so on Saturday (n = 7, 5.1%, chi-square = 30.44, P = .001). Stressor pattern, age and gender do not influence these increases of occurrence in summer, on Monday, and in the morning of TTC. CONCLUSIONS TTC seems to exhibit a temporal variation of occurrence with preferred peaks during morning, Monday, and summer. Stressor pattern, age and gender do not influence these temporal patterns of the occurrence of TTC. Further studies are needed to investigate the potential link between chronobiological variations of TTC onset and underlying pathophysiologic mechanisms.
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Affiliation(s)
- Bong Gun Song
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
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Song BG, Yang HS, Hwang HK, Kang GH, Park YH, Chun WJ, Oh JH. The impact of stressor patterns on clinical features in patients with tako-tsubo cardiomyopathy: experiences of two tertiary cardiovascular centers. Clin Cardiol 2012; 35:E6-13. [PMID: 23027688 DOI: 10.1002/clc.22053] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 08/01/2012] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Tako-tsubo cardiomyopathy (TTC) is typically triggered by an acute emotional or physical stress event. The aim of this study was to investigate the impact of stressor patterns on clinical features, laboratory parameters, and electrocardiographic and echocardiographic findings in patients with TTC. HYPOTHESIS Clinical features are different according to stressor patterns. METHODS Of 137 patients enrolled from the TTC registry database, 14 patients had emotional triggers (E group), 96 had physical triggers (P group), and 27 had no triggers (N group). RESULTS Most clinical presentations and in-hospital courses were similar among the groups. However, the E group had a higher prevalence of chest pain (P = 0.006) and palpitation (P = 0.006), whereas the P group had a higher prevalence of cardiogenic shock (P = 0.040), than other groups. The P group had a significantly higher heart rate (P = 0.001); higher high-sensitivity C-reactive protein (P = 0.006), creatine kinase MB fraction (P = 0.045), and N terminal-probrain natriuretic peptide (P = 0.036) levels; higher left ventricular end-diastolic pressure (P = 0.019) and left ventricular end-systolic diameter (P = 0.002); but lower left ventricular ejection fraction (P = 0.018). The E group had lesser prevalence of apical ballooning pattern (P = 0.038) than other groups. The P group required more frequent use of inotropics (P = 0.041) and diuretics (P = 0.047) and had significantly longer intensive care unit (P = 0.014) and in-hospital stays (P = 0.001). CONCLUSIONS The clinical features of TTC are different according to preceding stressor patterns. The TTC group with preceding physical stressors was less likely to have preserved cardiovascular reserve and more likely to require hemodynamic support than other groups. The overall prognosis of TTC is excellent, regardless of triggering stressors.
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Affiliation(s)
- Bong Gun Song
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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Coronary Vasospasm and Coronary Atherosclerosis. J Am Coll Cardiol 2012; 59:663-4. [DOI: 10.1016/j.jacc.2011.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/14/2011] [Indexed: 01/30/2023]
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Kang KM, Choi SI, Chun EJ, Kim JA, Youn TJ, Choi DJ. Coronary vasospastic angina: assessment by multidetector CT coronary angiography. Korean J Radiol 2011; 13:27-33. [PMID: 22247633 PMCID: PMC3253400 DOI: 10.3348/kjr.2012.13.1.27] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 08/18/2011] [Indexed: 01/12/2023] Open
Abstract
Objective We aimed to describe the imaging findings of multidetector CT coronary angiography (MDCTA) in cases of vasospastic angina (VA) and to determine the accuracy of MDCTA in the identification of VA as compared with invasive coronary angiography with an ergonovine provocation test (CAG with an EG test). Materials and Methods Fifty-three patients with clinically suspected VA were enrolled in this study. Two radiologists analyzed the stenosis degree, presence or absence of plaque, plaque composition, and a remodeling index of the related-segment in CAG with an EG test, which were used as a gold standard. We evaluated the diagnostic performances of MDCTA by comparing the MDCTA findings with those of CAG with an EG test. Results Among the 25 patients with positive CAG with an EG test, all 12 patients with significant stenosis showed no definite plaque with the negative arterial remodeling. Of the six patients with insignificant stenosis, three (50%) had non-calcified plaque (NCP), two (33%) had mixed plaque, and one (17%) had calcified plaque. When the criteria for significant stenosis with negative remodeling but no definite evidence of plaque as a characteristic finding of MDCTA were used, results showed sensitivities, specificities, positive predictive values (PPV), and negative predictive values (NPV) of 48%, 100%, 100%, and 68%, respectively. Conclusion Significant stenosis with negative remodeling, but no definite evidence of plaque, is the characteristic finding on MDCTA of VA. Cardiac MDCTA shows good diagnostic performance with high specificity and PPV as compared with CAG with an EG test.
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Affiliation(s)
- Koung Mi Kang
- Division of Cardiovascular Imaging, Department of Radiology, Cardiovascular Center Seoul National University Bundang Hospital, Gyeonggi-do 436-707, Korea
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Halna du Fretay X, Blanchard-Lemoine B, Schnebert B, Viossat J. [Variant angina: what to think in 2011?]. Ann Cardiol Angeiol (Paris) 2011; 60:317-323. [PMID: 22055431 DOI: 10.1016/j.ancard.2011.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Spastic angina is considered rare but its prevalence is probably underestimated especially in case of atherosclerotic coronary lesions. Its diagnosis remains important due to its poor prognosis and therapeutic characteristics. We report three clinical cases illustrating two different clinical presentations and the problem of diagnosis of spastic angina. We performed a review of the literature essentially concerning commonly used diagnosis means and especially provocative testing for coronary spasm. This test needs to be adapted to the evolution of techniques and uses of coronary angiography in 2011, particularly the wide spread use of radial approach. Therefore new recommendations are needed, specifying the terms of provocative testing and establishing clear diagnosis criteria including clinical, electrocardiographic and angiographic data. Such guidelines would probably help to better diagnose and treat these patients in our practice.
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Song BG, Chun WJ, Park YH, Kang GH, Oh J, Lee SC, Park SW, Oh JK. The clinical characteristics, laboratory parameters, electrocardiographic, and echocardiographic findings of reverse or inverted takotsubo cardiomyopathy: comparison with mid or apical variant. Clin Cardiol 2011; 34:693-9. [PMID: 22031226 DOI: 10.1002/clc.20953] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 07/20/2011] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Although takotsubo cardiomyopathy (TTC) typically affects the apical and/or midventricular segments, several recent cases have reported a reverse or inverted variant of TTC. The aim of this study was to investigate the clinical characteristics, laboratory parameters, electrocardiographic, and echocardiographic findings in patients presenting as inverted TTC and compare those parameters to those presenting as mid or apical variant. HYPOTHESIS The clinical features of inverted TTC are different from those of other types of TTC. METHODS Of 103 patients enrolled from the TTC registry database, 20 showed inverted TTC (inverted TTC group), and 83 showed mid or apical variant (other TTC group). RESULTS Clinical presentations and in-hospital courses were mostly similar between the groups. However, the inverted TTC group was younger (median, 54.5 vs 64.0 years; P = 0.006) than other TTC and had a higher prevalence of triggering stress (100% vs 77%, P = 0.018), whereas other TTC group had higher prevalence of dyspnea (58% vs 30%, P = 0.025), pulmonary edema (46% vs 20%, P = 0.035), cardiogenic shock (36% vs 10%, P = 0.023), T-wave inversion (81% vs 60%, P = 0.049), and significant reversible mitral regurgitation (MR) (19% vs 0%, P = 0.033). Also, the inverted TTC group had significantly higher creatine kinase MB fraction (CK-MB); CK-MB (median, 30.7 vs 7.6 ng/mL; P = 0.001) and troponin-I (median, 13.1 vs 1.6 ng/mL; P = 0.001), but lower N-terminalpro-brain natriuretic peptide (NT-proBNP) levels (median, 613.3 vs 4987.0 pg/mL; P = 0.020). CONCLUSIONS Inverted TTC presents at a younger age and has a higher prevalence of triggering stress, whereas other TTC has a higher prevalence of heart failure symptoms, significant reversible MR, and T-wave inversion and higher NT-proBNP levels despite other clinical features that are mostly similar.
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Affiliation(s)
- Bong Gun Song
- Department of Medicine, Division of Cardiology, Cardiac and Vascular Center, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
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Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2008): digest version. Circ J 2010; 74:1745-62. [PMID: 20671373 DOI: 10.1253/circj.cj-10-74-0802] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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