Multivessel Coronary Artery Spasm Refractory to Intensive Medical Treatment

Vasospastic angina: Past, present, and future

Vasospastic angina (VSA) is characterized by episodes of rest angina that are responsive to short-acting nitrates and are attributable to coronary artery vasospasm. The condition is underdiagnosed as the provocation test is rarely performed. VSA, the most important component of non-obstructive coronary artery disease, can present with angina, be asymptomatic, or can even present with fatal arrhythmias and cardiac arrest. Although most patients with VSA respond well to vasodilating medications, prognosis does not improve as expected in most patients, suggesting the existence elusive prognostic factors and pathogenesis that warrant further exploration. Moreover, patients with either severe or refractory VSA barely respond to conventional treatment and may develop life-threatening arrhythmias or suffer sudden cardiac death during ischemic attacks, which are associated with immune-inflammatory responses and have been shown to achieve remission following glucocorticoid and immunoglobulin treatments. Our recent work revealed that inflammation plays a key role in the initiation and development of coronary spasms, and that inflammatory cytokines have predictive value for diagnosis. In contrast to the existing literature, this review both summarizes the theoretical and clinical aspects of VSA, and also discusses the relationship between inflammation, especially myocarditis and VSA, in order to provide novel insights into the etiology, diagnosis, and treatment of VSA.

Responsiveness of Coronary Arteries to Nitroglycerin under Hypoxia: The Importance of the Endothelium

<b><i>Background/Aims:</i></b> Nitroglycerin is widely used as a coronary vasodilator in the treatment of ischemic heart diseases. This study investigated the influence of hypoxia on nitroglycerin-induced relaxation in endothelium-intact and -denuded rabbit, monkey, and porcine coronary arteries. <b><i>Methods:</i></b> Helically cut strips of coronary arteries were suspended in organ chambers, and isometric tension was recorded. <b><i>Results:</i></b> Nitroglycerin concentration dependently relaxed endothelium-intact rabbit coronary arteries, which were not different under normoxic and hypoxic conditions. On the other hand, nitroglycerin-induced relaxation of endothelium-denuded arteries was significantly attenuated by hypoxia. Similarly, the relaxant response of endothelium-intact monkey coronary arteries to nitroglycerin was not affected by hypoxia, whereas that of endothelium-denuded arteries was impaired. As is the case with rabbit and monkey coronary arteries, exposure to hypoxia resulted in impaired relaxation by nitroglycerin in endothelium-denuded but not endothelium-intact porcine coronary arteries. <b><i>Conclusion:</i></b> These findings suggest that coronary endothelium plays a pivotal role in preventing the hypoxia-induced impairment of nitroglycerin responsiveness, regardless of the animal species.

Successful treatment using corticosteroids in a patient with refractory vasospastic angina and bronchial asthma

We report a 55-year-old female patient with refractory vasospastic angina and bronchial asthma treated successfully with corticosteroids. She was diagnosed with vasospastic angina by coronary angiography and the acetylcholine provocation test. Even after administration of oral vasodilators (benidipine, diltiazem, nicorandil, isosorbide mononitrate) she had recurrent chest pain with ST elevation. She had a history of bronchial asthma, so we added 30 mg/day of oral prednisolone. Her symptoms disappeared completely upon treatment. This case report suggests that corticosteroids are a therapeutic choice for patients with refractory vasospastic angina, especially for those with bronchial asthma. <Learning objective: We report a 55-year-old female patient with refractory vasospastic angina and bronchial asthma. Even after administration of oral vasodilators, she had recurrent chest pain with ST elevation. She had a history of bronchial asthma, so we added 30 mg/day of oral prednisolone. Her symptoms disappeared completely upon treatment. This case report suggests that corticosteroids are a therapeutic choice for patients with refractory vasospastic angina, especially for those with bronchial asthma.>.