Refractory variant angina relieved by denopamine--a case report

Multivessel Coronary Artery Spasm Refractory to Intensive Medical Treatment

This case report describes multivessel coronary artery spasm refractory to oral nifedipine, intravenous isosorbide dinitrate, diltiazem and nicorandil, and intracoronary nitroglycerin. Intracoronary administration of nicorandil only transiently relieved coronary artery spasm. Prednisolone was effective in preventing coronary artery spasm.

Stent deformity caused by coronary artery spasm

Previous studies have shown that coronary stents have radial strength above the pressure induced by coronary artery spasm. This case report describes a stent deformity caused by coronary artery spasm during percutaneous coronary intervention.

Successful treatment of refractory vasospastic angina with corticosteroids: coronary arterial hyperactivity caused by local inflammation?

BACKGROUND

Although vasospastic angina usually responds well to treatment with calcium antagonists and/or nitrates, there have been anecdotal case reports of refractory vasospastic angina resistant to intensive treatment with high doses of calcium antagonists and nitrates.

METHODS AND RESULTS

Four patients with vasospastic angina, which was refractory to intensive treatment with high doses of calcium antagonists and nitrates, were completely controlled after administration of corticosteroids. Although none of the 4 patients showed eosinophilia, all had bronchial asthma or chronic thyroiditis, and in 2 cases, the activity of vasospastic angina corresponded with that of bronchial asthma.

CONCLUSIONS

These findings suggest that in these patients, coronary spasm may have been induced by arterial hyperreactivity because of local inflammation in the coronary arterial wall and that the corticosteroids suppressed the arterial hyperreactivity by alleviating the inflammation. Corticosteroids may be considered as a treatment choice for patients with refractory vasospastic angina, particularly when the patient has an allergic tendency, such as bronchial asthma.

Denopamine, a selective beta1-receptor agonist and a new coronary vasodilator

Up until now, it has been suggested that nitrate and/or calcium channel blockers were effective against variant angina pectoris. On the other hand, it is known that about 20% of variant angina pectoris was refractory to both nitrate and calcium channel blockers. In Japan, it has been reported that denopamine, which is an oral beta1-adrenoceptor selective agonist developed by the Japanese pharmaceutical industry (Tanabe Seiyaku), is effective in those refractory cases. To date, in Japan nine cases have been recognized of patients with vasospastic angina pectoris whose symptoms were relieved by taking denopamine, including one case in which the author has had personal experience. Eight of these nine cases were refractory, and were not relieved by combined therapy using both nitrate and a calcium channel blocker. It was also documented that denopamine was effective in cases where attacks were not relieved by prazosin or magnesium, which have been documented as effective in other refractory cases. In a study of canine coronary arteries, localization of beta-adrenoceptor subtypes was documented, with the beta1-adrenoceptor predominantly found in the conduit coronary artery. In recent years it has been emphasized that the principal role of sympathetic nerves was not associated with the constrictive action of alpha-adrenoceptors, but with the coronary dilative action of beta-adrenoceptors. It would therefore be worthwhile to determine whether denopamine is able to relieve vasospastic angina pectoris in many more cases.