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Kotta PA, Koduri AK, Berman J, Rosen VV, Kayani WT. The Great Masquerade: Not All Coronary Artery Stenosis Are Created Equal. Methodist Debakey Cardiovasc J 2024; 20:26-32. [PMID: 38799179 PMCID: PMC11122690 DOI: 10.14797/mdcvj.1365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/15/2024] [Indexed: 05/29/2024] Open
Abstract
We present the case of a 60-year-old male, with active smoking and cocaine use disorder, who reported progressive chest pain. Various anatomical and functional cardiac imaging, performed to further evaluate chest pain etiology, revealed changing severity and distribution of left main artery (LMA) stenosis, raising suspicion for vasospasm. Intracoronary nitroglycerin relieved the vasospasm, with resolution of the LMA pseudostenosis. A diagnosis of vasospastic angina (VA) led to starting appropriate medical therapy with lifestyle modification counselling. This case highlights VA, a frequently underdiagnosed etiology of angina pectoris. We discuss when to suspect VA, its appropriate work-up, and management.
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Wang C, Zhao X, Chen Y, Xia J, Zhang X, Wang T. Optimizing nicardipine dosage for effective control of pituitrin-induced hypertension in laparoscopic myomectomy undergoing total intravenous anesthesia. BMC Anesthesiol 2024; 24:155. [PMID: 38654209 PMCID: PMC11036747 DOI: 10.1186/s12871-024-02521-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/03/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND This study aimed to determine the median effective dose (ED50) and 95% effective dose (ED95) of nicardipine for treating pituitrin-induced hypertension during laparoscopic myomectomy, providing guidance for the management of intraoperative blood pressure in such patients. METHODS Among the initial 40 participants assessed, 24 underwent elective laparoscopic myomectomy. A sequential up-and-down method was employed to ascertain the ED50 of nicardipine based on its antihypertensive efficacy. Nicardipine was initially administered at 6 µg/kg following the diagnosis of pituitrin-induced hypertension in the first patient. Dosing adjustments were made to achieve the desired antihypertensive effect, restoring systolic blood pressure and heart rate to within ± 20% of baseline within 120 s. The dosing increment or reduction was set at 0.5 µg/kg for effective or ineffective responses, respectively. The ED50 and ED95 of nicardipine were calculated using Probit regression by Maximum Likelihood Estimation (MLE) to establish dose-response curves and confidence intervals. RESULTS 24 patients were included for analysis finally. The ED50 and ED95 of nicardipine for blood pressure control after pituitrin injection were determined. The study found that the ED50 of nicardipine for treating pituitrin-induced hypertension was 4.839 µg/kg (95% CI: 4.569-5.099 µg/kg), and the ED95 was estimated at 5.308 µg/kg (95% CI: 5.065-6.496 µg/kg). Nicardipine effectively mitigated the hypertensive response caused by pituitrin without inducing significant tachycardia or hypotension. CONCLUSIONS Nicardipine effectively controlled blood pressure after pituitrin injection during laparoscopic myomectomy, with ED50 and ED95 values established. This research highlights the potential utility of nicardipine in addressing hypertensive responses induced by pituitrin, particularly in clinical settings where pituitrin is routinely administered.
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Affiliation(s)
- Chen Wang
- Department of Anaesthesia, Seventh People's Hospital of Shanghai Universityof Traditional Chinese Medicine, Shanghai, 200137, China
| | - Xiaoli Zhao
- Department of Anaesthesia, Seventh People's Hospital of Shanghai Universityof Traditional Chinese Medicine, Shanghai, 200137, China
| | - Yunyun Chen
- Department of Anaesthesia, Changning Maternity and Infant Health Hospital, Shanghai, 200050, China
| | - Jianhua Xia
- Department of Anaesthesia, Shanghai Pudong New Area People´s Hospital, Shanghai, 201299, China
| | - Xixue Zhang
- Department of Anaesthesia, Huadong Hospital affiliated to Fudan University, No 221, West Yan'an Road, Shanghai, 200040, China.
| | - Tingting Wang
- Department of Anaesthesia, Seventh People's Hospital of Shanghai Universityof Traditional Chinese Medicine, Shanghai, 200137, China.
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Yaker ZS, Lincoff AM, Cho L, Ellis SG, Ziada KM, Zieminski JJ, Gulati R, Gersh BJ, Holmes D, Raphael CE. Coronary spasm and vasomotor dysfunction as a cause of MINOCA. EUROINTERVENTION 2024; 20:e123-e134. [PMID: 38224252 PMCID: PMC10786177 DOI: 10.4244/eij-d-23-00448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/15/2023] [Indexed: 01/16/2024]
Abstract
Increasing evidence has shown that coronary spasm and vasomotor dysfunction may be the underlying cause in more than half of myocardial infarctions with non-obstructive coronary arteries (MINOCA) as well as an important cause of chronic chest pain in the outpatient setting. We review the contemporary understanding of coronary spasm and related vasomotor dysfunction of the coronary arteries, the pathophysiology and prognosis, and current and emerging approaches to diagnosis and evidence-based treatment.
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Affiliation(s)
- Zachary S Yaker
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Leslie Cho
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stephen G Ellis
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Khaled M Ziada
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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4
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Cai H, Chen S, Wang D. Sudden diffuse spasm of multiple coronary arteries: A case report. Medicine (Baltimore) 2024; 103:e36889. [PMID: 38215100 PMCID: PMC10783403 DOI: 10.1097/md.0000000000036889] [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: 09/12/2023] [Accepted: 12/18/2023] [Indexed: 01/14/2024] Open
Abstract
RATIONALE Diffuse multivessel coronary artery spasm (DMV-CAS) was defined as a severe and reversible diffuse spasm occurring in more than 2 major coronary arteries, which is rare in clinical practice. Due to a wide lesion scope, DMV-CAS often occurs in the form of complications. It is not easy to be clinically diagnosed because it is too brief to be caught. Here, we report a rare case of spontaneous subtotal occlusion of 3 major coronary arteries induced by Vasalva action, which was confirmed in real-time by CAG. PATIENT CONCERNS A 68-year-old man had sudden chest pain after forced defecation during hospitalization. The electrocardiogram showed transient ST segment elevation of the inferior wall lead, inversion of the anterior wall, and lateral wall leads T waves. Emergency CAG revealed elongated vessel beds in 3 coronary arteries and multiple diffuse stenosis, but none of the coronary arteries were completely occlusive. DIAGNOSES Diagnoses of DMV-CAS were made based on CAG findings and postmedication response. INTERVENTIONS Nitroglycerin was administered in the coronary arteries. The anti-vasospasm, antiplatelet aggregation and lipid-regulating drugs were administered orally. OUTCOMES The patient was discharged on the 7th day with complete resolution of symptoms and normalization of the electrocardiography findings. No ischemic events occurred during a follow-up for 5 months. LESSONS This case highlights the identification of multivessel diffuse coronary spasm and acute myocardial infarction, and the prevention of CAS triggers, which requires the attention of clinicians.
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Affiliation(s)
- Hui Cai
- Department of Cardiology, Hebei General Hospital, Hebei North University, Shijiazhuang, Hebei Province, China
| | - Shuxia Chen
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei Province, China
| | - Dongxiao Wang
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei Province, China
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5
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Jenkins K, Pompei G, Ganzorig N, Brown S, Beltrame J, Kunadian V. Vasospastic angina: a review on diagnostic approach and management. Ther Adv Cardiovasc Dis 2024; 18:17539447241230400. [PMID: 38343041 PMCID: PMC10860484 DOI: 10.1177/17539447241230400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/17/2024] [Indexed: 02/15/2024] Open
Abstract
Vasospastic angina (VSA) refers to chest pain experienced as a consequence of myocardial ischaemia caused by epicardial coronary spasm, a sudden narrowing of the vessels responsible for an inadequate supply of blood and oxygen. Coronary artery spasm is a heterogeneous phenomenon that can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction (MI). VSA was originally described as Prinzmetal angina or variant angina, classically presenting at rest, unlike most cases of angina (though in some patients, vasospasm may be triggered by exertion, emotional, mental or physical stress), and associated with transient electrocardiographic changes (transient ST-segment elevation, depression and/or T-wave changes). Ischaemia with non-obstructive coronary arteries (INOCA) is not a benign condition, as patients are at elevated risk of cardiovascular events including acute coronary syndrome, hospitalization due to heart failure, stroke and repeat cardiovascular procedures. INOCA patients also experience impaired quality of life and associated increased healthcare costs. VSA, an endotype of INOCA, is associated with major adverse events, including sudden cardiac death, acute MI and syncope, necessitating the study of the most effective treatment options currently available. The present literature review aims to summarize current data relating to the diagnosis and management of VSA and provide details on the sequence that treatment should follow.
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Affiliation(s)
- Kenny Jenkins
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Graziella Pompei
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Nandine Ganzorig
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Brown
- Cardiovascular Care Partnership, British Cardiovascular Society, London, UK
| | - John Beltrame
- Basil Hetzel Institute for Translational Health Research, Adelaide Medical School, University of Adelaide and Royal Adelaide Hospital and The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University Medical School, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
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Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
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Sousa CP, Sales F, Teixeira F, Seabra D, Cunha M. Anesthetic Management of a Patient With Prinzmetal Angina. Cureus 2023; 15:e41857. [PMID: 37581162 PMCID: PMC10423314 DOI: 10.7759/cureus.41857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/16/2023] Open
Abstract
Prinzmetal angina (PA) is characterized by the development of reversible vasoconstriction of the coronary arteries, transient ischemic electrocardiographic changes in the ST segment, chest pain at rest, and prompt response to nitrates. Spasms of the coronary arteries can be precipitated during the perioperative period by an imbalance of vasodilator and vasoconstrictor factors of smooth muscle cells, which can lead to myocardial ischemia, cardiac arrhythmias, and death. Nevertheless, this is a relatively unrecognized topic, and literature is scarce about it. We present a case report detailing the successful anesthetic management of a patient diagnosed with PA and a documented nitrate allergy, who underwent bilateral ureterorenoscopy.
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Affiliation(s)
- Cristina P Sousa
- Anesthesiology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, PRT
| | - Filipa Sales
- Anesthesiology Department, Hospital Pedro Hispano, Matosinhos, PRT
| | - Francisco Teixeira
- Anesthesiology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, PRT
| | - Daniel Seabra
- Cardiology Service, Medicine Department, Hospital Pedro Hispano, Matosinhos, PRT
| | - Mariana Cunha
- Anesthesiology Department, Hospital Pedro Hispano, Matosinhos, PRT
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8
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Jin J, Xia G, Luo Y, Cai Y, Huang Y, Yang Z, Yang Q, Yang B. Case report: Implantable cardioverter-defibrillator implantation with optimal medical treatment for lethal ventricular arrhythmia caused by recurrent coronary artery spasm due to tyrosine kinase inhibitors. Front Cardiovasc Med 2023; 10:1145075. [PMID: 36998979 PMCID: PMC10045981 DOI: 10.3389/fcvm.2023.1145075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 02/14/2023] [Indexed: 03/16/2023] Open
Abstract
Coronary artery spasm (CAS) may induce lethal ventricular arrhythmia due to severe and prolonged vessel constriction. Tyrosine kinase inhibitors are associated with the occurrence of CAS. Optimal medical treatment is the first-line therapeutic option for the management of CAS, whereas patients who experienced aborted sudden cardiac death (SCD) may benefit from implantable cardioverter-defibrillator (ICD) implantation. We report a case of a 63-year-old Chinese man receiving tyrosine kinase inhibitor treatment for liver cancer who presented with recurrent chest discomfort and syncope with an elevation of high-sensitivity troponin T. Emergent coronary angiography showed sub-total occlusion of the left anterior descending artery without other signs of CAS. Percutaneous transluminal coronary angioplasty with a drug-coated balloon was performed successfully with the guidance of intravascular ultrasound. After 5 months, the patient returned to the emergency room for chest discomfort and another episode of syncope. The electrocardiogram showed ST-segment elevation in the inferior and V5–V6 leads compared to the previous event. Coronary angiography was repeated immediately and showed significant luminal stenosis at the midportion of the right coronary artery (RCA), whereas, after administration of intracoronary nitroglycerine, a remarkable recovery of RCA patency was noticed. A diagnosis of CAS was made, and soon after that, the patient rapidly developed ventricular arrhythmia in the coronary care unit. After successful resuscitation, the patient recovered completely and received long-acting calcium channel blockers as well as nitrates therapy. ICD implantation was performed considering the high risk of recurrence of life-threatening ventricular arrhythmia. During the follow-up period, the patient has been free of angina, syncope, or ventricular arrhythmia, and ICD interrogation showed no ventricular tachycardia or ventricular fibrillation. We first reported the case of a patient with CAS induced by regorafenib treatment complicated with severe atherosclerotic coronary disease who survived from sudden cardiac arrest. ICD implantation is indicated in patients who experienced aborted SCD for the prevention of the next lethal ventricular arrhythmia.
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9
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Yao YY, Zhang LL, Zhao LX, Luo DL. Tortuous diagnosis and treatment of a patient with coronary vasospastic angina(VSA). Asian J Surg 2023; 46:1524-1525. [PMID: 36202704 DOI: 10.1016/j.asjsur.2022.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/14/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Yan-Ying Yao
- Chengde Central Hospital/Second Clinical College of Chengde Medical University, Chengde, China
| | - Li-Ling Zhang
- Chengde Central Hospital/Second Clinical College of Chengde Medical University, Chengde, China
| | - Li-Xia Zhao
- Chengde Central Hospital/Second Clinical College of Chengde Medical University, Chengde, China.
| | - Dong-Lei Luo
- Chengde Central Hospital/Second Clinical College of Chengde Medical University, Chengde, China.
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10
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Singh J, Elton A, Kwa M. Comparison of various calcium antagonist on vasospastic angina: a systematic review. Open Heart 2023; 10:openhrt-2022-002179. [PMID: 36634997 PMCID: PMC9843173 DOI: 10.1136/openhrt-2022-002179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/21/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Coronary artery vasospasm is an abnormal spasm of coronary arteries that cause transient or complete occlusion without exertion. It causes stable angina to ACS. However, this can be prevented by calcium channel blockers (CCBs) which suppress Ca2+ influx into the vascular muscle cells. Nevertheless, several CCBs adverse effects are harmful for these patients. Selecting the right CCBs would give the best clinical practice. METHOD The studies were obtained from four major medical databases by various keywords. Inclusion and exclusion criteria were implemented as adult >18 years, observational study, English language and drug of interest. Duplicates were eliminated, and the remaining studies were reviewed. Final full-texts assessment was conducted independently by Newcastle-Ottawa Scale and Revised Cochrane. RESULTS The search found 1378 articles. However, six studies were selected after implementing the study criteria. Diltiazem was found to decrease angina and increase quality of life until 12th week of treatment; however, some adverse effects include atrioventricular block and recurrent angina up till 4th week were found. Meanwhile, nifedipine was found to decrease vasospastic angina (VSA) by the fourth and eighth weeks of treatment. Nevertheless, it caused excessive drop in BP and increase heart rate by eighth week. In addition, slow-release preparation of both CCBs were found to increase efficacy and compliance. Lastly amlodipine was also found to decrease VSA by 17%±140% and 33% after 6 weeks, but further studies needed. CONCLUSION Diltiazem, nifedipine and amlodipine are potent in decreasing VSA, however, tailoring specific CCBs adverse reactions to patient condition and the drug preparation would be substantially beneficial for the outcome.
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Affiliation(s)
- Jaspal Singh
- Emergency Department, Rumah Sakit Umum Daerah Dr Pirngadi Kota Medan, Medan, Indonesia
| | - Andre Elton
- Mitra Keluarga Hospital Group, Jakarta, Indonesia
| | - Melvin Kwa
- University of Indonesia Hospital, Depok, Jawa Barat, Indonesia
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11
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Belfar AL, Deng Y, Yu RC, Sabbagh A. Successful Use of Continuous Erector Spinae Plane Blocks in a Patient With Variant Angina After Large Ventral Hernia Repair. Tex Heart Inst J 2022; 49:489335. [PMID: 36534113 PMCID: PMC9809071 DOI: 10.14503/thij-21-7624] [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: 12/23/2022]
Abstract
Coronary artery spasm constitutes the primary underlying pathology of variant angina. Because provocation of coronary artery spasm may occur with both excess sympathetic and excess parasympathetic stimulation, patients with this disorder have extremely limited options for perioperative pain control. This is especially true for procedures involving extensive abdominal incision/manipulation. Whereas neuraxial analgesia might otherwise be appropriate in these cases, several studies have demonstrated that coronary artery spasm can occur as a result of epidural placement, and therefore, that this may not be an optimal choice for patients with variant angina. This report discusses the case of a patient with a preexisting diagnosis of variant angina who underwent an exploratory laparotomy with large ventral hernia repair and for whom continuous erector spinae plane blocks were successfully used as analgesic adjuncts without triggering coronary artery spasm.
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Affiliation(s)
| | - Yi Deng
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
| | - Raymond C. Yu
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Annas Sabbagh
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, Pennsylvania
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12
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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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13
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Qilin L, Yanbin Z, Huaizhi L, Tao Z, Miao Y, Yi X, Dayong D, Yang L, Yuntian L. Effect of Statins on Clinical Outcomes in Patients With Coronary Artery Spasm: A Meta-Analysis. Clin Ther 2022; 44:971-981. [PMID: 35715362 DOI: 10.1016/j.clinthera.2022.05.007] [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: 10/05/2021] [Revised: 04/14/2022] [Accepted: 05/15/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this meta-analysis was to assess the effect of statins on major adverse cardiovascular events (MACE) related to coronary artery spasm (CAS) and to evaluate the effectiveness of statins in patients with CAS. METHODS A systematic search of electronic databases, including Google Scholar, the Cochrane Central Register of Controlled Trials, and PubMed, was conducted. These studies were all published in English, and the databases were searched from inception to July 2021. All articles were evaluated independently by 2 researchers on the basis of inclusion and exclusion criteria. In the research, data about the incidence of major adverse cardiovascular events in CAS patients undergoing statin therapy was included and divided into different subgroups. A random effects model was conducted to synthesize the data. FINDINGS Five cohort studies were included in the analysis. These results indicated that statins failed to reduce the incidence of stroke in patients with CAS in general. However, subgroup analysis revealed that statins were more effective in improving outcomes for CAS patients without severe coronary stenosis compared with those with severe coronary stenosis. IMPLICATIONS Statins may have a potential benefit in patients with CAS who do not have coronary stenosis. To investigate these findings further, future prospective, randomized controlled research will be required.
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Affiliation(s)
- Liu Qilin
- Second Clinical Medical College of Southern Medical University, Guangzhou, China
| | - Zhang Yanbin
- Longyan First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Lu Huaizhi
- Shangqiu People's Hospital, henan, China
| | - Zhang Tao
- Second Clinical Medical College of Southern Medical University, Guangzhou, China
| | - Yang Miao
- Second Clinical Medical College of Southern Medical University, Guangzhou, China
| | - Xue Yi
- PLA 305 Hospital, Beijing, China
| | | | - Liu Yang
- PLA 305 Hospital, Beijing, China
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14
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Adachi K, Hayashi T, Omatsu T, Hirayama A, Higuchi Y. Idiopathic Effusive-Constrictive Pericarditis Presented by Variant Angina. Cureus 2021; 13:e14380. [PMID: 33987048 PMCID: PMC8110287 DOI: 10.7759/cureus.14380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
An 80-year-old man presented to our hospital complaining of loss of appetite. During the medical examination, he developed variant angina accompanied with heart failure. Oral calcium channel blocker therapy controlled his variant angina, but medical management of heart failure became increasingly difficult due to gradually increasing pericardial effusion, and pericardiocentesis leading to the diagnosis of effusive-constrictive pericarditis (ECP). Here, we report a rare case of idiopathic pericarditis caused variant angina with already having endothelial dysfunction and eventually developed ECP.
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Affiliation(s)
- Kentaro Adachi
- Cardiovascular Medicine, Osaka Police Hospital, Osaka, JPN
| | | | - Takashi Omatsu
- Cardiovascular Medicine, Osaka Police Hospital, Osaka, JPN
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Ischemia in patients with no obstructive coronary artery disease: classification, diagnosis and treatment of coronary microvascular dysfunction. Coron Artery Dis 2020; 31:472-476. [DOI: 10.1097/mca.0000000000000855] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Jia S, Liu Y, Yuan J. Evidence in Guidelines for Treatment of Coronary Artery Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1177:37-73. [PMID: 32246443 DOI: 10.1007/978-981-15-2517-9_2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In this chapter, we focus on evidences in current guidelines for treatment of coronary artery disease (CAD). In Part 1, diet and lifestyle management is discussed, which plays an important role in CAD risk control, including forming healthy dietary pattern, maintaining proper body weight, physical exercise, smoking cessation, and so on. Part 2 elaborated on revascularization strategies and medical treatments in patients presenting with acute coronary syndrome (ACS), including specific AHA and ESC guidelines on ST elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS). Part 3 discussed chronic stable coronary artery disease (SCAD), the treatment objective of which is a combination of both symptomatic and prognostic improvement. Yet many of the recommendations for SCAD are expert-based rather than evidence-based. Initial medical treatment is safe and beneficial for most patients. While cumulating studies have focused on optimizing pharmacological therapy (referring to nitrates, beta-blockers, calcium channel blockers, antiplatelet agents, ACEI/ARB, statins, etc.), education, habitual modification, and social support matters a lot for reducing cardiac morbidity and mortality. Patients with moderate-to-severe symptoms and complex lesions should be considered for revascularization. But practical management of revascularization shall take individual characteristics, preference, and compliance into consideration as well.
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Affiliation(s)
- Sida Jia
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue Liu
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinqing Yuan
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Tandon V, Mosebach CM, Kumar M, Joshi S. Refractory Vasospastic Angina: When Typical Medications Don't Work. Cureus 2019; 11:e4134. [PMID: 31058017 PMCID: PMC6485519 DOI: 10.7759/cureus.4134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Vasospastic angina (VSA) is defined as spasm of the coronaries leading to transient constriction and eventual myocardial ischemia. VSA is treated typically with calcium-channel blockers (CCBs) and nitrates. However, there are times when the vasospasm is refractory to typical medications. When this occurs, unconventional treatment modalities may be employed for symptomatic relief. We present a case of a 48-year-old-male with a history of inferior ST-elevation myocardial infarction (STEMI) status post percutaneous coronary intervention (PCI) with drug-eluting stent (DES) to the distal right coronary artery (RCA), who presented with recurrent angina. The pain was described as pressure-like, substernal, radiating to both arms, and similar to his previous STEMI presentation. On presentation to the emergency room, he had an elevated serum troponin with no electrocardiogram (EKG) changes. He was taken to the cath lab where it was found that he revealed severe focal stenosis just proximal to the previously placed stent. Immediately after guidewire passage into the RCA, acute vasospasm developed, resulting in diffuse, severe stenosis, extending over previously normal segments to the proximal RCA, resolving with intracoronary nicardipine and nitroglycerin, including the initial focal stenosis. The patient was diagnosed with VSA. Unfortunately, despite optimal medical therapy, he developed refractory VSA, requiring the use of unconventional treatment methods. Our patient presented with a lesser-known phenomenon called refractory VSA, where intermittent vasospasm continues despite being on a combination of two medications. Treatment for VSA is well-documented, however, little data is available for refractory VSA.
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Affiliation(s)
- Varun Tandon
- Internal Medicine, University of Connecticut, Farmington, USA
| | | | - Manish Kumar
- Internal Medicine, University of Connecticut, Farmington, USA
| | - Saurabh Joshi
- Cardiology, University of Connecticut, Farmington, USA
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Abstract
INTRODUCTION Angina pectoris is the most prevalent symptomatic manifestation of ischemic heart disease, frequently leads to a poor quality of life, and is a major cause of medical resource consumption. Since the early descriptions of nitrite and nitrate in the 19th century, there has been considerable advancement in the pharmacologic management of angina. Areas covered: Management of chronic angina is often challenging for clinicians. Despite introduction of several pharmacological agents in last few decades, a significant proportion of patients continue to experience symptoms (i.e., refractory angina) with subsequent disability. For the purpose of this review, we searched PubMed and Cochrane databases from inception to August 2016 for the most clinically relevant publications that guide current practice in angina therapy and its development. In this article, we briefly review the pathophysiology of angina and mechanism-based classification of current therapy. This is followed by evidence-based insight into the traditional and novel pharmacotherapeutic agents, highlighting their clinical usefulness. Expert opinion: Considering the wide array of available therapies with different mechanism efficacy and limiting factors, a personalized approach is essential, particularly for patients with refractory angina. Ongoing research with novel pharmacologic modalities is likely to provide new options for management of angina.
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Affiliation(s)
- Ankur Jain
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Islam Y Elgendy
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Mohammad Al-Ani
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Nayan Agarwal
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Carl J Pepine
- a Department of Medicine , University of Florida , Gainesville , FL , USA
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Mishra S, Ray S, Dalal JJ, Sawhney JPS, Ramakrishnan S, Nair T, Iyengar SS, Bahl VK. Management standards for stable coronary artery disease in India. Indian Heart J 2016; 68 Suppl 3:S31-S49. [PMID: 28038722 PMCID: PMC5198886 DOI: 10.1016/j.ihj.2016.11.320] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Coronary artery disease (CAD) is one of the important causes of cardiovascular morbidity and mortality globally, giving rise to more than 7 million deaths annually. An increasing burden of CAD in India is a major cause of concern with angina being the leading manifestation. Stable coronary artery disease (SCAD) is characterised by episodes of transient central chest pain (angina pectoris), often triggered by exercise, emotion or other forms of stress, generally triggered by a reversible mismatch between myocardial oxygen demand and supply resulting in myocardial ischemia or hypoxia. A stabilised, frequently asymptomatic phase following an acute coronary syndrome (ACS) is also classified as SCAD. This definition of SCAD also encompasses vasospastic and microvascular angina under the common umbrella.
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Affiliation(s)
- Sundeep Mishra
- Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | | | | | - J P S Sawhney
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - S Ramakrishnan
- Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | | | | | - V K Bahl
- Department of Cardiology, AIIMS, New Delhi, India
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