Changes in autonomic nervous activity prior to spontaneous coronary spasm in patients with variant angina

Morbidity in early Parkinson's disease and prior to diagnosis

BACKGROUND

Nonmotor symptoms are probably present prior to, early on, and following, a diagnosis of Parkinson's disease. Nonmotor symptoms may hold important information about the progression of Parkinson's disease.

OBJECTIVE

To evaluated the total early and prediagnostic morbidities in the 3 years before a hospital contact leading to a diagnosis of Parkinson's disease.

METHODS

Retrospective morbidity data from Danish National Patient Registry records (1997-2007) of 10,490 adult patients with a secondary care diagnosis of Parkinson's disease were compared with 42,505 control cases.

RESULTS

Parkinson's disease was associated with significantly higher morbidity rates associated with conditions in the following categories: mental and psychiatric, nervous system, gastrointestinal, musculoskeletal system and connective tissue, genitourinary, abnormal clinical and laboratory findings, injury, poisoning and certain other external causes, and other factors influencing health status and contact with health services. It was negatively associated with neoplasm, cardiovascular, and respiratory diseases.

CONCLUSIONS

Patients with a diagnosis of Parkinson's disease present significant differences in morbidities early on, following, and prior to, their diagnosis, compared with healthy controls.

Cardiac syndrome X and microvascular coronary dysfunction

Women with cardiac chest pain indicated by signs and symptoms of myocardial ischemia in the absence of obstructive CAD are often labelled as cardiac syndrome X (CSX). A subset of patients with CSX may have symptoms of ischemia due to microvascular dysfunction. Angina due to microvascular coronary dysfunction (MCD) is an etiologic mechanism in women with vascular dysfunction. New data provide improve understanding of coronary vascular dysfunction and resultant myocardial ischemia that characterize MCD among patients with cardiac syndrome X. MCD has an adverse prognosis and health care cost expenditure comparable to obstructive CAD. The high prevalence of this condition, particularly in women, adverse prognosis and substantial health care costs, coupled with a lack of evidence regarding treatment strategies, places MCD as a research priority area.

Clinical and angiographic characteristics of acute myocardial infarction caused by vasospastic angina without organic coronary heart disease

BACKGROUND

Vasospastic angina (VA) can occasionally cause acute myocardial infarction (AMI).

METHODS AND RESULTS

From January 2003 to June 2005, coronary spastic angina was diagnosed in 292 patients by performing spasm provocation tests. Among the 292 patients, 21 (7.2% of all the VA patients) had an AMI. There were 20 patients who initially visited the emergency room for AMI without suffering prior VA. One patient with a history of VA had an AMI when he discontinued his medication. Among the 21 VA patients with AMI, 14 had experienced severe emotional stress before they visited the emergency room. The spasm provocation test showed that the VA patients with AMI had more multivessel and diffuse spasm than the VA patients without AMI (p<0.001).

CONCLUSION

Clinically, the VA patients with AMI usually had their first symptom of VA as the severe chest pain of AMI. Two-thirds of the VA patients with AMI had experienced emotional stress before their AMI. Angiographically, the spasm provocation test for VA patients with AMI showed more multivessel and diffuse spasm than in VA patients without AMI.

Coronary vasospasm-induced acute coronary syndrome complicated by life-threatening cardiac arrhythmias in patients without hemodynamically significant coronary artery disease

BACKGROUND

Coronary vasospasm-induced electrical and mechanical complications in patients with acute coronary syndrome and no hemodynamically significant coronary artery disease are rarely reported.

METHODS

A total of 733 consecutive patients with acute coronary syndrome admitted to our hospital who subsequently underwent coronary angiography at our institution were enrolled. Patients who had documented complete atrioventricular block or ventricular fibrillation, no evidence of hemodynamically significant coronary artery disease on coronary angiogram, and no other (non-coronary) cardiac abnormalities were included. Patients were followed for subsequent cardiac events and mortality.

RESULTS

Over a 6-year period at our institution, acute coronary syndrome complicated by life-threatening cardiac arrhythmias developed in six patients who had no hemodynamically significant coronary artery disease with corresponding intra-coronary ergonovine provocative coronary vasospasm. Acute myocardial infarction was diagnosed in five of these patients and variant angina pectoris in one. Complete atrioventricular block was the most common complication in these cases, followed by cardiogenic shock with or without right ventricular infarction, ventricular fibrillation, and severe sinus arrest. These complications were corrected with intravenous fluid, intravenous atropine or cardiac defibrillation. During a median follow-up period of 26 months, none of the patients expired or suffered nonfatal reinfarction. Two individuals who did not stop smoking during follow-up developed recurrent angina after self-discontinuation of calcium antagonists.

CONCLUSIONS

Coronary vasospasm can be a cause of life-threatening cardiac arrhythmias in patients with acute coronary syndrome and no hemodynamically significant coronary artery disease. Coronary angiography with/without intra-coronary ergonovine testing is necessary in acute coronary syndrome patients to identify the underlying pathology and establish appropriate treatment in these cases.

Recurrent intraoperative coronary artery spasm in a patient with coronary artery aneurysm

Coronary artery spasm (CAS) may result from endothelial dysfunction in nonobstructed arteries. Its complications include myocardial infarction, dysrhythmias, and death. It is difficult to diagnose CAS during general anesthesia because it closely mimics obstructive ischemia. We report the case of a patient who demonstrated intraoperative CAS during two separate surgeries. Angiography after the first surgery showed nonobstructed coronary anatomy. During the second surgery, recurrence of acute ST elevations caused by CAS rapidly responded to nitroglycerin. A high index of suspicion for CAS as a cause of intraoperative ischemia is necessary for an early diagnosis, treatment, and a favorable outcome.

Vagal nerve-mediated vasospasm-induced lethal ventricular fibrillation

We report a case of variant angina complicated by lethal ventricular fibrillation. Serial ambulatory electrocardiogram monitoring revealed high-frequency spectra reflecting augmented vagal nerve activity preceding the vasospastic episodes. Our case suggests that heart rate variability analysis can help identify potential unexpected sudden cardiac death in patients with variant angina.

Inhomogeneous derangement of cardiac autonomic nerve control in diabetic rats

The present study compared autonomic nervous function in Kob [Spontaneously Diabetic, Bio-Breeding (BB)] rats with control Wistar rats to determine the development of cardiac neuropathy in diabetic rats. Telemetric ECG signals were obtained from an ECG radio-transmitter placed in a dorsal subcutaneous pouch of male Kob and Wistar rats for 30min every 6h at a sample rate of 5kHz. Heart rate (HR) and HR variability (HRV) were analyzed in each group by power spectrograms obtained by a fast Fourier transform algorithm. RR interval, total power (TP), low frequency (LF) power (0.04-0.67 Hz), high frequency (HF) power (0.79-1.48 Hz) and LF/HF ratio were also measured. The Kob rats had lower HRV than the control Wistar rats; HR, TP, and HF power, but not the LF/HF ratio, in the Kob rats were significantly lower than those of the control rats (p<0.001). However, in the Kob rats the response of these parameters to a muscarinic antagonist (atropine: 2mg/kg) was left intact, but their response to a beta-adrenergic antagonist (propranolol: 4mg/kg) was impeded. Autonomic nervous control of HR in spontaneously diabetic rats was inhomogeneously deranged in terms of the balance in sympathetic and parasympathetic tone, not only in the baseline condition, but also in the regulatory systems, including postsynaptic receptor function.

Tetrahydrobiopterin improves coronary endothelial function, but does not prevent coronary spasm in patients with vasospastic angina

Reduced bioavailability of tetrahydrobiopterin (BH4), an essential cofactor for nitric oxide (NO) synthase, and the resulting decrease in NO in the coronary circulation may be involved in the pathogenesis of coronary spasm. The present study investigated the effects of BH4 on the vascular response to acetylcholine (ACh) in 28 patients with vasospastic angina (VA) using quantitative angiography. After recording the vascular responses to ACh (3 and 30 microg/min), either BH4 (1 mg/min) or saline was infused into the coronary artery for 2 min before and during a subsequent infusion of ACh. With the 3 microg/min dose of ACh, BH4 attenuated the ACh-induced decrease in coronary diameter in both the nonspastic segments (-1.1 +/- 2.2% ACh vs 6.0 +/- 2.8% ACh+BH4) and spastic segments (-6.3 +/- 2.7% ACh vs 2.9 +/- 2.7% ACh+BH4), but did not influence the ACh-induced coronary spasm at 30 microg/min (-57.3 +/-2.4% ACh vs -55.3 +/- 2.4% ACh+BH4). In the control patients, saline did not influence either the spastic or nonspastic vasoconstrictor responses to ACh. Acute administration of BH4 improves coronary endothelial function, but does not prevent coronary spasm in patients with VA.