Comparison of clinical outcomes in patients with mixed angina and pure vasospastic angina

OBJECTIVE

This study investigated differences in clinical outcomes between mixed angina (MA) and pure vasospastic angina (PVA).

METHODS

A total of 524 vasospastic angina patients who did or did not have >50% coronary artery stenosis from January 2005 to January 2021 were divided into two groups (Group 1: PVA, N  = 399; Group 2: MA, N  = 125) and then three groups [Group 1: PVA, N  = 399; Group 2: MA without percutaneous coronary intervention (PCI), N  = 67; Group 3: MA with PCI, N  = 58] for assessment. We recorded the incidence of major adverse cardiac and cerebrovascular events (MACCE: the composite of death, myocardial infarction, nonfatal stroke or rehospitalization) during 3-year clinical follow-up.

RESULTS

Compared to the PVA group, there were significant differences in MACCE (20.8% vs. 11.8%, P  = 0.011) and rehospitalization (20.0% vs. 9.8%, P  = 0.002) in the MA group. Kaplan-Meier analysis showed that patients in the MA with PCI group had the highest cumulative incidence rate of MACCE during the 3-year follow-up (log-rank P  < 0.001).

CONCLUSION

Compared with the PVA patients, MA patients had significantly worse clinical outcomes during long-term follow-up.

Association of the interleukine-6 polymorphism with catheter-induced coronary artery spasm in Egyptians

BACKGROUND

The role of coronary artery spasm (CAS) was extended beyond variant angina to ischemic heart disease in general, including effort angina, unstable angina, acute myocardial infarction (MI) and sudden death. It is difficult and cumbersome to examine CAS during coronary angiography. Risk factors for CAS include smoking and genetic polymorphisms.

AIM

We aimed to investigate the association of the interleukin-6 (IL-6) polymorphism with catheter-induced CAS in Egyptian patients who undergo coronary angiography.

METHODS

This is a case-control study. Two hundred patients with chronic coronary artery disease who underwent elective coronary angiography were included in the study. Patients were divided into two groups: the non-CAS group (100 patients) and the CAS group (100 patients). The subjects were genotyped to the -572 C>G (rs 1800796) polymorphism of the IL-6 gene by PCR-restriction fragment length polymorphism.

RESULTS

We found that patients with CAS have more risk factors for atherosclerosis compared to those without CAS. Smoking, the IL-6 GG genotype, and the G allele were independent risk factors for CAS.

CONCLUSION

We concluded that the GG genotype and G allele of the IL-6 gene are associated with CAS. Smoking, the GG genotype, and the G allele of the IL-6 gene are independent predictors of catheter-induced CAS.

Long-term prognostic factors for cardiovascular events in patients with chest pain without diabetes mellitus nor significant coronary stenosis

Chest pain is the most common symptom of coronary artery disease (CAD) and diabetes mellitus (DM) is a well-known single strongest risk factor for cardiovascular diseases. Thus, the impact of CAD nor DM on long-term clinical effects is reported widely, but the prognostic factors of non-DM patients presenting with chest pain without significant CAD are limited. A total of 1,046 patients with chest pain without DM and significant CAD who underwent coronary angiography (CAG) and acetylcholine (ACH) provocation tests were finally enrolled. Propensity score matching and multivariate Cox-proportional hazard ratio analysis were performed to adjust for baseline potential confounders. Major adverse cardiac and cerebrovascular events (MACCE) were defined as the composite of total death, myocardial infarction (MI), revascularization, stroke, and recurrent angina. This study aimed to evaluate the long-term prognostic factors for MACCE in patients with chest pain without DM and CAD up to 5 years. Coronary artery spasm (CAS) was the most common cause of chest pain. However, long-term MACCE of CAS was not worse than those of patients with chest pain without CAS when patients with CAS had subsequent optimal antianginal medication therapy. However, a recurrent chest pain remains a problem even with continuous antianginal medication therapy. Up to 5 years, the incidence of MACCE was in 7.3%, including recurrent angina 6.9%. Dyslipidemia (HR: 2.010, 95% CI 1.166-3.466, P = 0.012), mild-moderate (30-70%) coronary stenosis (HR: 2.369, 95% CI 1.118-5.018, P = 0.024), the use of aspirin (HR: 2.885, 95% CI 1.588-5.238, P < 0.001), and the use of nitrates (HR: 1.938, 95% CI 1.094-3.433, P = 0.023) were independent risk factors for MACCE. Among the patients with chest pain without DM and significant CAD, the incidence of MACE were rare, but recurrent angina was still a challenging problem who had treated with antianginal medications.

Comparison of the Diagnostic Yield of Intracoronary Acetylcholine Infusion and Acetylcholine Bolus Injection Protocols During Invasive Coronary Function Testing

Coronary endothelial dysfunction (CED) and coronary artery spasm (CAS) are causes of angina with no obstructive coronary arteries in patients. Both can be diagnosed by invasive coronary function testing (ICFT) using acetylcholine (ACh). This study aimed to evaluate the diagnostic yield of a 3-minute ACh infusion as compared with a 1-minute ACh bolus injection protocol in testing CED and CAS. We evaluated 220 consecutive patients with angina and no obstructive coronary arteries who underwent ICFT using continuous Doppler flow measurements. Per protocol, 110 patients were tested using 3-minute infusion, and thereafter 110 patients using 1-minute bolus injections, because of a protocol change. CED was defined as a <50% increase in coronary blood flow or any epicardial vasoconstriction in reaction to low-dose ACh and CAS according to the Coronary Vasomotor Disorders International Study Group (COVADIS) criteria, both with and without T-wave abnormalities, in reaction to high dose ACh. The prevalence of CED was equal in both protocols (78% vs 79%, p = 0.869). Regarding the endotypes of CAS according to COVADIS, the equivocal endotype was diagnosed less often in the 3 vs 1-minute protocol (24% vs 44%, p = 0.004). Including T-wave abnormalities in the COVADIS criteria resulted in a similar diagnostic yield of both protocols. Hemodynamic changes from baseline to the low or high ACh doses were comparable between the protocols for each endotype. In conclusion, ICFT using 3-minute infusion or 1-minute bolus injections of ACh showed a similar diagnostic yield of CED. When using the COVADIS criteria, a difference in the equivocal diagnosis was observed. Including T-wave abnormalities as a diagnostic criterion reclassified equivocal test results into CAS and decreased this difference. For clinical practice, we recommend the inclusion of T-wave abnormalities as a diagnostic criterion for CAS and the 1-minute bolus protocol for practicality.

Relationship between Inflammation and Vasospastic Angina

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.

Sex-related Differences in Patients with Positive Coronary Spasm as Identified by Acetylcholine Testing

Objective A pathological acetylcholine (ACh) test was observed at lower ACh doses in females compared with males in European populations. We retrospectively analyzed the sex-related differences in Japanese patients with provoked positive spasm by ACh spasm provocation testing. Methods We performed the ACh spasm provocation tests in 1,854 patients from Jan 1991 until Mar 2019. ACh was injected in incremental doses of 20/50/100/200 μg into the left coronary artery and 20/50/80 μg into the right coronary artery. Positive spasm was defined as >90% stenosis and usual chest pain or ischemic ECG changes. We compared the clinical characteristics, angiographical findings during ACh testing, and clinical outcomes between female and male patients with and without provoked positive spasm. Results Positive provoked spasm was diagnosed in 917 patients including 737 (80.4%) males and 180 (19.6%) females. The incidence of provoked positive spasm in females was significantly lower than that in males (33.5% vs. 56.0%, p<0.001). Female patients with provoked positive spasm tended to be older, have less history of smoking, less provoked spasm in the left circumflex artery, or less focal type spasm than male patients with provoked positive spasm. The incidence of ST elevation during ACh testing in male patients was significantly higher than that in female patients, whereas the frequency of ST depression in females was remarkably higher than that in males. The mean maximum used ACh dose for provoked positive spasm on both coronary arteries in female patients was significantly higher than that in male patients. The observed major complications during ACh testing did not differ substantially between the sexes. In addition, the prognosis in females with provoked positive spasm was not different from males. Conclusion Provoked positive spasm by ACh test was obtained at lower mean maximum ACh doses in males compared with females in Japanese patients.

Ischemia and No Obstructive Coronary Artery Disease: Prevalence and Correlates of Coronary Vasomotion Disorders

BACKGROUND

Determine the prevalence and correlates of microvascular and vasospastic angina in patients with symptoms and signs of ischemia but no obstructive coronary artery disease (INOCA).

METHODS

Three hundred ninety-one patients with angina were enrolled at 2 regional centers over 12 months from November 2016 (NCT03193294). INOCA subjects (n=185; 47%) had more limiting dyspnea (New York Heart Association classification III/IV 54% versus 37%; odds ratio [OR], 2.0 [1.3-3.0]; P=0.001) and were more likely to be female (68% INOCA versus 38% in coronary artery disease; OR, 1.9 [1.5 to 2.5]; P<0.001) but with lower cardiovascular risk scores (ASSIGN score median 20% versus 24%; P=0.003). INOCA subjects had similar burden of angina (Seattle Angina Questionnaire) but reduced quality of life compared with coronary artery disease; subjects (EQ5D-5 L index 0.60 versus 0.65 units; P=0.041).

RESULTS

An interventional diagnostic procedure with reference invasive tests including coronary flow reserve, microvascular resistance, and vasomotor responses to intracoronary acetylcholine (vasospasm provocation) was performed in 151 INOCA subjects. Overall, 78 (52%) had isolated microvascular angina, 25 (17%) had isolated vasospastic angina, 31 (20%) had both, and 17 (11%) had noncardiac chest pain. Regression analysis showed inducible ischemia on treadmill testing (OR, 7.5 [95% CI, 1.7-33.0]; P=0.008) and typical angina (OR, 2.7 [1.1-6.6]; P=0.032) were independently associated with microvascular angina. Female sex tended to associate with a diagnosis of microvascular angina although this was not significant (OR, 2.7 [0.9-7.9]; P=0.063). Vasospastic angina was associated with smoking (OR, 9.5 [2.8-32.7]; P<0.001) and age (OR, 1.1 per year, [1.0-1.2]; P=0.032].

CONCLUSIONS

Over three quarters of patients with INOCA have identifiable disorders of coronary vasomotion including microvascular and vasospastic angina. These patients have comparable angina burden but reduced quality of life compared to patients with obstructive coronary artery disease. Microvascular angina and vasospastic angina are distinct disorders that may coexist but differ in associated clinical characteristics, symptoms, and angina severity.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT03193294.

The multi-vessel and diffuse coronary spasm is a risk factor for persistent angina in patients received anti-angina medication

Coronary artery spasm (CAS) is known to be a risk factor for cardiovascular events. However, there is limited data whether the multi-vessel and diffuse spasm (MVDS) is related to more adverse clinical outcomes compared to the Non-MVDS. The aim of this study is to evaluate the impact of the MVDS on clinical outcomes during a 3-year clinical follow-up period.A total 2797 patients underwent coronary angiography (CAG) with acetylcholine (ACH) provocation test from Nov 2004 to Oct 2010 were enrolled. It is a single-center, observational, prospective, all-comers registry designed to reflect the "real world" practic. The patients were divided into the 3 groups; the negative spasm (NS) group (n = 1188), the Non-MVDS group (n = 1081), and the MVDS group (n = 528). The incidence of major adverse cardiac events (MACE) and recurrent angina was evaluated up to 3 years. To minimize confounding factors, multivariable Cox-proportional hazards regression analysis was performed.In the 3-year clinical follow-up, the incidence of total death, myocardial infarction, de novo percutaneous coronary intervention (PCI), cerebrovascular accident and MACE were similar among the 3 groups. However, recurrent angina occurred more frequently in the MVDS group than in the NS group (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.27-3.02; P = .002). Recurrence angina between the MVDS group and the Non-MVDS group was not statistically significant (HR, 1.36; 95% CI, 0.91-2.03; P = .129).In this study, although the incidence of major adverse cardiovascular events were not different regardless of spasm type, the MVDS was associated with higher incidence of recurrent chest pain requiring repeat CAG during the 3-year follow-up period, suggesting more intensive optimal medical therapy with close clinical follow up would be necessary for this particular subset of patients.

Sex-Related Differences in Vasomotor Function in Patients With Angina and Unobstructed Coronary Arteries

BACKGROUND

Coronary vasomotor dysfunction is an important mechanism for angina in patients with unobstructed coronary arteries.

OBJECTIVES

The purpose of this study was to determine sex differences in the prevalence and clinical presentation of vasomotor dysfunction in a European population and to examine sex differences in the dose of acetylcholine leading to a positive acetylcholine provocation test (ACH test).

METHODS

Between 2007 and 2014, we included 1,379 consecutive patients with stable angina, unobstructed coronaries and ACH test performed for epicardial vasospasm or coronary microvascular dysfunction (CMD) due to microvascular spasm. The predictive value of sex, risk factors, symptoms, and noninvasive test results was analyzed by means of logistic regression.

RESULTS

The mean patient age was 62 years, and 42% were male. There were 813 patients (59%) with a pathological ACH test, 33% for CMD and 26% for epicardial vasospasm. A pathological test was more common in females (70% vs. 43%; p < 0.001). In a multivariable logistic regression model the sex difference was statistically significant with a female-male odds ratio for CMD and epicardial vasospasm of 4.2 (95% confidence interval: 3.1 to 5.5; p < 0.001) and 2.3 (95% confidence interval: 1.7 to 3.1; p < 0.001), respectively. Effort-related symptoms, but neither risk factors nor noninvasive stress tests, contributed to predicting a pathological test. Female patients were more sensitive to acetylcholine with vasomotor dysfunction occurring at lower ACH doses compared with male patients.

CONCLUSIONS

Vasomotor dysfunction is frequent in patients with angina and unobstructed coronaries in a European population. Female patients have a higher prevalence of vasomotor dysfunction (especially CMD) compared with male patients. A pathological ACH test was observed at lower ACH doses in women compared with men.

Recognition and Management of Resistant Hypertension

Despite improvements in hypertension awareness and treatment, 30%-60% of hypertensive patients do not achieve BP targets and subsequently remain at risk for target organ damage. This therapeutic gap is particularly important to nephrologists, who frequently encounter treatment-resistant hypertension in patients with CKD. Data are limited on how best to treat patients with CKD and resistant hypertension, because patients with CKD have historically been excluded from hypertension treatment trials. First, we propose a consistent definition of resistant hypertension as BP levels confirmed by both in-office and out-of-office measurements that exceed appropriate targets while the patient is receiving treatment with at least three antihypertensive medications, including a diuretic, at dosages optimized to provide maximum benefit in the absence of intolerable side effects. Second, we recommend that each patient undergo a standardized, stepwise evaluation to assess adherence to dietary and lifestyle modifications and antihypertensive medications to identify and reduce barriers and discontinue use of substances that may exacerbate hypertension. Patients in whom there is high clinical suspicion should be evaluated for potential secondary causes of hypertension. Evidence-based management of resistant hypertension is discussed with special considerations of the differences in approach to patients with and without CKD, including the specific roles of diuretics and mineralocorticoid receptor antagonists and the current place of emerging therapies, such as renal denervation and baroreceptor stimulation. We endorse use of such a systematic approach to improve recognition and care for this vulnerable patient group that is at high risk for future kidney and cardiovascular events.

Comparison of long-term clinical outcomes of percutaneous coronary intervention in vasospastic angina patients associated with significant coronary artery stenosis

BACKGROUND

Coronary spasm is the major pathophysiology of vasospastic angina (VA). Medical treatment is usually effective in VA patients without significant stenosis. However, there is little information about the percutaneous coronary intervention (PCI) in VA patients with significant coronary artery stenosis (CAS).

METHODS

After retrospective screening of all consecutive VA patients from January 2010 to April 2015, we selected significant CAS (>50% of diameter stenosis) after nitrate injection and divided them into two groups according to the presence of PCI.

RESULTS

A total of 220 VA patients (41 females, mean age: 58±10years old) were screened, and 85 were included in this study. Males were predominant in the VA with significant CAS group (89 vs 76%, p=0.020). PCI was done in 43 patients (51%). The most common culprit coronary artery was the left anterior descending coronary artery (18, 42%), diameter stenosis was significantly higher (66±9 vs 61±10%, p<0.01), and total number of antianginal medication was significantly lower in the PCI group than in the medical group (1.7±0.9 vs 2.1±0.8, p=0.039). Moreover, 4 patients underwent PCI to control symptoms in the medical treatment group during the follow-up period (26±13months). However, additional antiplatelet therapy was necessary in patients with coronary angioplasty, and there were 2 cases with complication associated with angioplasty (1 restenosis and 1 bleeding complication).

CONCLUSION

In VA patients with significant CAS, both treatment modalities showed similar clinical outcomes. Although the PCI can afford symptomatic improvement, it needed additional antiplatelet medications and can be associated with procedural complications.

Impact of Statin Therapy on Clinical Outcome in Patients With Coronary Spasm

BACKGROUND

Statin therapy reduces the risk of cardiovascular events in patients with obstructive coronary artery disease. The aim of the present study was to determine the effects of statins on the prognosis of patients with coronary vasospastic angina (VSA) free of significant atherosclerotic stenosis.

METHODS AND RESULTS

After exclusion of 475 from 1877 consecutive patients who underwent an acetylcholine-provocation test between January 1991 and December 2010, data of 640 VSA patients without significant organic stenosis of the remaining 1402 were analyzed retrospectively. Propensity score matching was performed to reduce the effect of treatment-selection bias and possible confounders. The primary endpoint was major adverse cardiac events (MACE), including cardiac death, nonfatal myocardial infarction, and unstable angina. Among the study population, dyslipidemia on admission was identified in 160 of 168 (95.2%) patients of the statin group compared with only 125 of 472 (26.5%) of the no-statin group. Of the 640 patients, 24 (3.8%) developed MACE. Multivariate Cox hazard regression analysis identified statin therapy as a significant negative predictor of MACE (hazard ratio, 0.11; 95% CI, 0.02-0.84; P=0.033). In the propensity-score matched cohorts (n=128 each), Kaplan-Meier survival curve showed a better 5-year MACE-free survival rate for patients of the statin group compared to the no-statin group (100% vs 91.7%, respectively; P=0.002).

CONCLUSIONS

Statin therapy correlated with a lower rate of cardiovascular events in VSA patients free of significant organic stenosis. Statins seems to improve the prognosis of VSA patients free of significant organic stenosis.

[Dobutamine-related coronary spasm among patients with false positive dobutamine stress echocardiography: Prevalence and predictors]

BACKGROUND AND OBJECTIVE

Dobutamine stress echocardiography (DSE) is being consistently used as an exercise-independent stress modality aimed at the detection of coronary artery disease (CAD) and the evaluation of myocardial ischemia. It may though occasionally induce coronary vasospasm. In this study, we aimed to evaluate the prevalence and predictors of dobutamine-related coronary spasm in patients without known CAD and false positive DSE (positive DSE but no significant coronary lesions on angiogram).

METHODS

Three thousand nine hundred and fifty-two patients referred to our echocardiography laboratory for DSE between January 2010 and May 2012 were prospectively investigated. Those with positive DSE underwent coronary angiograms with systematic methylergometrine intracoronary injection in case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients with spontaneous occlusive coronary spasm or positive methylergometrine test but no significant stenoses were enrolled and compared with those with positive DSE but no coronary lesions nor spontaneous or induced spasm ("true" false positive DSE).

RESULTS

Twenty-nine patients with DSE-related vasospasm (19.4% of positive DES without known CAD) were compared with 56 patients with no lesions and no spasm ("true" false positive DSE). They were more frequently smokers (72.4% vs 37.5%; P=0.003); they had more frequently dyslipidemia (79.3% vs 43%; P=0.001); they also had a larger ischemic area at peak DSE (3.4 segments vs 2.7 segments; P=0.05). On multivariate analysis, dyslipidemia (HR=10.7; 95% CI=[2.7-42.1]; P=0.001) and active smoking (HR=6.1; 95% CI=[1.7-21.1]; P=0.004) were found to be independent predictors of spasm-related DSE rather than "true" false positive DSE.

CONCLUSION

DSE-related coronary spasm is present in a significant proportion of patients with erroneously labelled "false" positive DSE and should systematically be ruled out. Dyslipidemia and active smoking were independent predictors of spasm rather than "true" false positive DSE.

Diabetes mellitus is not a risk factor for coronary artery spasm as assessed by an intracoronary acetylcholine provocation test: angiographic and clinical characteristics of 986 patients

OBJECTIVES

Both diabetes mellitus (DM) and coronary artery spasm (CAS) are associated with endothelial dysfunction. Thus, a higher incidence of CAS is expected in diabetic patients (pts). We evaluated the impacts of DM and the status of blood sugar control on CAS with intracoronary acetylcholine (ACh) provocation test.

METHODS

A total of 986 pts (106 DM vs 880 non-DM pts) with angiographically normal coronary artery received ACh provocation test. Significant CAS was defined as a transient >90% luminal narrowing with concurrent chest pain and/ or ST-segment changes. HbA1c <7% was considered a controlled blood sugar level.

RESULTS

The incidence of CAS was similar between patients with versus without DM (30.2% vs 23.5%; P=.13). Multivariable analysis showed that DM was not an independent risk factor for significant CAS (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.81-2.07; P=.28). The angiographic characteristics of CAS were also similar between these two groups. Subgroup analysis regarding the impact of the status of blood sugar control on CAS showed that the incidence of CAS was similar between diabetic pts with versus without controlled blood sugar levels (35.4% vs 25.9%; P=.29). Multivariable analysis showed that the uncontrolled blood sugar level was not an independent risk factor for CAS (OR, 0.79; 95% CI, 0.29-2.13; P=.64).

CONCLUSIONS

Despite the expected endothelial dysfunction, DM and the status of blood sugar control are not associated with CAS, suggesting the existence of different mechanisms for CAS and coronary artery disease.

Characteristics of resistant hypertension in a large, ethnically diverse hypertension population of an integrated health system

OBJECTIVE

To evaluate the prevalence of and characterize resistant hypertension in a large representative population with successful hypertension management and reliable health information.

PATIENT AND METHODS

We performed a cross-sectional study using clinical encounter, laboratory, and administrative information from the Kaiser Permanente Southern California health system between January 1, 2006, and December 31, 2007. From individuals older than 17 years with hypertension, resistant hypertension was identified and prevalence was determined. Multivariable logistic regression was used to calculate odds ratios (ORs), with adjustments for demographic characteristics, clinical variables, and medication use.

RESULTS

Of 470,386 hypertensive individuals, 60,327 (12.8%) were identified as having resistant disease, representing 15.3% of those taking medications. Overall, 37,061 patients (7.9%) had uncontrolled hypertension while taking 3 or more medicines. The ORs (95% CIs) for resistant hypertension were greater for black race (1.68 [1.62-1.75]), older age (1.11 [1.10-1.11] for every 5-year increase), male sex (1.06 [1.03-1.10]), and obesity (1.46 [1.42-1.51]). Medication adherence rates were higher in those with resistant hypertension (93% vs 89.8%; P<.001). Chronic kidney disease (OR, 1.84; 95% CI, 1.78-1.90), diabetes mellitus (OR, 1.58; 95% CI, 1.53-1.63), and cardiovascular disease (OR, 1.34; 95% CI, 1.30-1.39) were also associated with higher risk of resistant hypertension.

CONCLUSION

In a more standardized hypertension treatment environment, we observed a rate of resistant hypertension comparable with that of previous studies using more fragmented data sources. Past observations have been limited due to nonrepresentative populations, reliability of the data, heterogeneity of the treatment environments, and less than ideal control rates. This cohort, which was established using an electronic medical record-based approach, has the potential to provide a better understanding of resistant hypertension and outcomes.

Coronary vasomotor response to intracoronary acetylcholine injection, clinical features, and long-term prognosis in 873 consecutive patients with coronary spasm: analysis of a single-center study over 20 years

BACKGROUND

The aim of this study was to elucidate the correlation between angiographic coronary vasomotor responses to intracoronary acetylcholine (ACh) injection, clinical features, and long-term prognosis in patients with vasospastic angina (VSA).

METHODS AND RESULTS

This is a retrospective, observational, single-center study of 1877 consecutive patients who underwent ACh-provocation test between January 1991 and December 2010. ACh-provoked coronary spasm was observed in 873 of 1637 patients included in the present analysis. ACh-positive patients were more likely to be older male smokers with dyslipidemia, to have a family history of ischemic heart disease, and to have a comorbidity of coronary epicardial stenosis than were ACh-negative patients. ACh-positive patients were divided into 2 groups: those with focal (total or subtotal obstruction, n=511) and those with diffuse (severe diffuse vasoconstriction, n=362) spasm patterns. Multivariable logistic regression analysis identified female sex and low comorbidity of coronary epicardial stenosis to correlate with the ACh-provoked diffuse spasm pattern in patients with VSA. Kaplan-Meier survival curve indicated better 5-year survival rates free from major adverse cardiovascular events in patients with diffuse spasm pattern compared with those with focal spasm pattern (P=0.019). Multivariable Cox hazard regression analysis identified diffuse spasm pattern as a negative predictor of major adverse cardiovascular events in patients with VSA.

CONCLUSIONS

ACh-induced diffuse coronary spasm was frequently observed in female VSA patients free of severe coronary epicardial stenosis and was associated with better prognosis than focal spasm. These results suggest the need to identify the ACh-provoked coronary spasm subtypes in patients with VSA.

High prevalence of a pathological response to acetylcholine testing in patients with stable angina pectoris and unobstructed coronary arteries. The ACOVA Study (Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries)

OBJECTIVES

This study aimed at determining the prevalence of epicardial and microvascular coronary spasm in patients with anginal symptoms, despite angiographically normal coronary arteries.

BACKGROUND

Despite a typical clinical presentation with exercise-related anginal symptoms (chest pain or dyspnea) with or without occasional attacks of resting chest pain suggestive of coronary artery disease, 40% of patients undergoing diagnostic angiography have normal or "near" normal coronary arteriograms. Many of these patients are given a diagnosis of noncardiac chest pain, and some are considered to have microvascular angina. However, we speculate that abnormal coronary vasomotion (reduced vasodilatation with exercise = reduced coronary flow reserve and/or vasospasm at rest) might also represent a plausible explanation for the symptoms of the patient.

METHODS

This was a prospective study in 304 consecutive patients (50% men, mean age 66 ± 10 years) with exertional anginal symptoms undergoing diagnostic angiography. A total of 139 patients (46%) had ≥50% coronary artery disease in at least 1 coronary artery, 21 patients (7%) had luminal narrowings ranging from >20% to 49%, and 144 patients (47%) had normal coronary arteries or only minimal irregularities (<20% diameter reduction).

RESULTS

One hundred twenty-four patients of the latter (86%) underwent intracoronary acetylcholine (ACH) testing, which elicited coronary spasm in 77 patients (62%), 35 patients (45%) with epicardial spasm (≥75% diameter reduction with reproduction of the symptoms of the patient) and 42 patients (55%) with microvascular spasm (reproduction of symptoms, ischemic electrocardiographic changes, and no epicardial spasm).

CONCLUSIONS

Nearly 50% of patients undergoing diagnostic angiography for assessment of stable angina had angiographically normal or near normal coronary arteriograms. The ACH test triggered epicardial or microvascular coronary spasm in nearly two-thirds of these patients. Our results suggest that abnormal coronary vasomotion plays a pathogenic role in this setting and that the ACH test might be useful to identify patients with cardiac symptoms, despite normal coronaries. (Abnormal Coronary Vasomotion in Patients With Suspected CAD But Normal Coronary Arteries; NCT00921856).

Angiographic and clinical characteristics of patients with acetylcholine-induced coronary vasospasm on follow-up coronary angiography following drug-eluting stent implantation

Recent studies have shown that drug-eluting stents (DES) induce vascular endothelial dysfunction in both Cypher and Taxus stents. These studies evaluated coronary vasomotion in the peristent coronary segment for 1 lesion with 1 DES. The angiographic and clinical characteristics of real-world patients with coronary spasm following DES implantation have not been well documented.

METHODS AND RESULTS

All patients at our hospital who underwent coronary angiography at follow up after DES deployment (Cypher and Taxus stents) between July 2007 and March 2009 were included. We performed an acetylcholine (ACh) provocation test for diagnosing coronary vasospasm in 3 vessels, except in patients with significant stenosis or contraindications to ACh administration. ACh provocation test was positive in 36/55 of the coronary arteries (65.4%) and in 30/42 of the patients with DES (71.4%). There was no difference in the positive rate between patients with and without symptoms. A total of 13/20 asymptomatic patients (65.0%) also showed positive results. In patients with positive results in the ACh provocation test, vasoconstriction at segments distal to the stent was exaggerated compared with corresponding segments in non-stented vessels (0.46 ± 0.27 versus 0.31 ± 0.20, respectively; p = 0.008). Vessels with positive results had a longer stent length compared with those with negative results (31.6 ± 13.6 mm versus 24.2 ± 11.2 mm, respectively; p = 0.049).

CONCLUSION

Coronary vasoconstriction was exaggerated at distal segments in DES-implanted vessels compared to non-stented vessel segments and stent length was longer in the ACh provocation test positive group.

Incidence and predictors of radial artery spasm during transradial coronary angiography and intervention

BACKGROUND

Radial artery spasm (RAS) is the most common complication in transradial coronary angiography and intervention. In this study, we designed to investigate the incidence of RAS during transradial procedures in Chinese, find out the independent predictors through multiple regression, and analyze the clinical effect of RAS during follow-up.

METHODS

Patients arranged to receive transradial coronary angiography and intervention were consecutively enrolled. The incidence of RAS was recorded. Univariate analysis was performed to find out the influence factors of RAS, and logistic regression analysis was performed to find out the independent predictors of RAS. The patients were asked to return 1 month later for the assessment of the radial access.

RESULTS

The incidence of RAS was 7.8% (112/1427) in all the patients received transradial procedure. Univariate analysis indicates that young (P = 0.038), female (P = 0.026), small diameter of radial artery (P < 0.001), diabetes (P = 0.026), smoking (P = 0.019), moderate or severe pain during radial artery cannulation (P < 0.001), unsuccessful access at first attempt (P = 0.002), big sheath (P = 0.004), number of catheters (> 3) (P = 0.048), rapid baseline heart rate (P = 0.032) and long operation time (P = 0.021) were associated with RAS. Logistic regression showed that female (OR = 1.745, 95%CI: 1.148 - 3.846, P = 0.024), small radial artery diameter (OR = 4.028, 95%CI: 1.264 - 12.196, P = 0.008), diabetes (OR = 2.148, 95%CI: 1.579 - 7.458, P = 0.019) and unsuccessful access at first attempt (OR = 1.468, 95%CI: 1.212 - 2.591, P = 0.032) were independent predictors of RAS. Follow-up at (28 +/- 7) days after the procedure showed that, compared with non-spasm patients, the RAS patients had higher portion of pain (11.8% vs. 6.2%, P = 0.043). The occurrences of hematoma (7.3% vs. 5.6%, P = 0.518) and radial artery occlusion (3.6% vs. 2.6%, P = 0.534) were similar.

CONCLUSIONS

The incidence of RAS during transradial coronary procedure was 7.8%. Logistic regression analysis showed that female, small radial artery diameter, diabetes and unsuccessful access at first attempt were the independent predictors of RAS.

[Potential risk caused by the lack of recognition of coronary spasm: analysis of the coronary spasm questionnaire in Japan]

BACKGROUND

The spasm provocation test (SPT)is no longer widely used in patients with undiagnosed chest pain syndromes in the USA and Europe. Objectives. The clinical significance of the SPT was examined in Japan and compared with the frequency of coronary spastic angina (CSA) in institutions with and without SPT screening.

METHODS AND RESULTS

Questionnaires concerning the number of cases of coronary angiography (CAG), percutaneous coronary intervention (PCI), and invasive/non-invasive SPT in 2005 were sent to members of the Japanese Circulation Society in 1,177 cardiology hospitals. Completed surveys were returned from 208 hospitals (17.7%). Non-invasive SPT was performed in only 27 hospitals (13.0%). Invasive SPT was not performed in 50 (24.0%) institutions, and performed in the remaining 158 institutions(< 10 cases/year: 29.8%, > or = 10< 50: 33.7%, > or = 50< 100: 8.7%, > or = 100: 3.8%). There was a close correlation between the number of acetylcholine/ergonovine SPTs and the number of CSA cases finally diagnosed (acetylcholine: r(2)= 0.907, ergonovine: r(2) = 0.76). There was no difference in the number/year of CAG (525+/-451 vs 513 +/-888, NS) and PCI(175+/-156 vs 144+/-225, NS) between institutions with and without SPT screening. However, the number of CSA cases (15.6+/-21.6 vs 4.2 +/-13.0, p < 0.01) and variant angina cases (3.3+/-7.2 vs 1.4+/-2.4)in hospitals with SPT screening was higher than hospitals without SPT screening.

CONCLUSIONS

If Japanese cardiologists discontinue use of the SPT as in the USA and Europe, occurrence of CSA may disappear in the near future in Japan.

Nitroglycerin, nitroprusside, or both, in preventing radial artery spasm during transradial artery catheterization

OBJECTIVE

Radial artery spasm remains a major complication of transradial coronary interventions. The aim of this study was to compare the efficacy of three different intra-arterial vasodilating cocktails in reducing the incidence of radial artery spasm in patients undergoing transradial coronary angiography. The secondary goal was to assess the predictors of arterial spasm in this large group of patients.

METHODS

A total of 379 patients undergoing the procedure were randomly enrolled in 1 of 3 groups. Every patient in each of the 3 groups received intra-arterial heparin, lidocaine and diltiazem. Along with that, patients in Group A received nitroglycerin; patients in Group B received nitroprusside instead of nitroglycerin; and patients in Group C received both nitroglycerin and nitroprusside. A single experienced operator, blinded to the study drug, subjectively determined the presence of spasm.

RESULTS

Of 379 patients, a total of 44 patients (11.6%) experienced spasm. The occurrence of spasm was similar, independent of the vasodilator cocktail used (Group A: 12.2%, Group B: 13.4%, Group C: 9.5%; p = 0.597). After multivariate analysis, the following variables were found to be independent predictors of spasm: radial artery diameter (RD)/height index (p = 0.005), RD/BSA index (p = 0.012), and sheath outer diameter (OD)/RD index (p = 0.024).

CONCLUSION

In this prospective, randomized trial, the addition of a direct nitric oxide donor to nitroglycerin in an antispastic cocktail did not reduce the risk of spasm, and the use of nitroglycerin was found to be as effective as nitroprusside. Also, morphometric and mechanical factors play a significant role in predicting the occurrence of radial spasm. The sex of the patient, presence of diabetes, body surface area and smoking history appeared to play no role in predicting the occurrence of radial spasm.

Ergonovine test in angina with normal coronary arteries. Is it worth doing it?

BACKGROUND

Patients with angina and normal coronary arteries are often misdiagnosed with having non-cardiac pain. Although vasospasm is a well-known entity, spasm provocation is not routinely done in the majority of hospitals at present.

MATERIALS AND METHODS

One hundred and sixty two consecutive patients with thoracic pain and normal coronary arteries were retrospectively studied. The characteristics of pain were analysed. One hundred and sixty one non-invasive tests (with and without imaging) were done to 126 patients before angiography. Increasing doses of ergonovine (from 1 to 30 microg) were injected into the coronary arteries to provoke coronary spasm. The correlation between ergonovine-induced spasm and non-invasive tests was studied.

RESULTS

Oppressive thoracic pain suggestive of angina was present in 144 patients. It occurred at rest in 59 patients, only at night in 14, with effort in 40, and it was mixed in 31. Non-oppressive atypical pain was reported by 18 patients. Non-invasive tests were 94 positive, 60 negative and 7 non-diagnostic. Ergonovine test elicited coronary spasm in 85 patients (52.5%). No significant correlation was found between the positivity of a non-invasive test and ergonovine-induced spasm.

CONCLUSIONS

More than half of the patients with angina and normal coronary arteries can be diagnosed with vasospastic angina if ergonovine test is performed. Even patients with a negative non-invasive test maybe sent to coronary angiography when vasospastic angina is suspected, in order to have an accurate diagnosis.

Coronary artery vasospasm causing acute myocardial infarction in a heart transplant recipient

The etiology of cardiac allograft vasculopathy is not known, but may be preceded by both endothelial cell and smooth muscle dysfunction of the epicardial coronary arteries. We here report a case of acute, reversible coronary artery vasospasm which caused a myocardial infarction in a cardiac transplant recipient. The patient had a complex post-transplant course, including an episode of severe vascular rejection several months before this presentation. Interestingly, the event was captured in its early stages because the patient presented with chest pain: a rare event because of the denervation of the transplanted heart. Our ability to document the etiology of this patient's myocardial infarction supports the concept that cardiac allograft vasculopathy is a progressive disease that, in its early stages, may include a reversible component of abnormal vasoreactivity.

Genetic risk and gene?environment interaction in coronary artery spasm in Japanese men and women

AIMS

The aim of the study was to identify genes that confer susceptibility to coronary artery spasm and clarify the interaction between genetic and environmental factors in this condition.

METHODS AND RESULTS

The study population comprised 2188 Japanese individuals, including 593 subjects with coronary artery spasm (453 men, 140 women) and 1595 controls (762 men, 833 women). The genotypes for 35 polymorphisms of 29 candidate genes were determined with an allele-specific DNA primer-probe assay. Multivariable logistic regression analysis adjusted for age, body mass index, and the prevalence of smoking, hypertension, diabetes mellitus, hypercholesterolaemia, and hyperuricaemia revealed a significant association with coronary artery spasm of one polymorphism (242C-->T in the NADH/NADPH oxidase p22 phox gene) in men and two polymorphisms (-1171/5A-->6A in the stromelysin-1 gene and -634C-->G in the interleukin-6 gene) in women. A stepwise forward selection procedure revealed that smoking was the most important risk factor for coronary artery spasm and that the effects of these polymorphisms on this condition were statistically independent of smoking.

CONCLUSION

The NADH/NADPH oxidase p22 phox gene is a susceptibility locus for coronary artery spasm in men, and the stromelysin-1 and interleukin-6 genes are susceptibility loci in women.

[Intraoperative coronary spasm in non-cardiac surgery]

BACKGROUND

Cardiovascular events are one of the most critical perioperative complications. The purpose of this study is to investigate the clinical characteristics, effective treatments, and clinical outcome of intraoperative coronary spasm through a review of the published literature.

METHODS

Reports of intraoperative coronary spasm were identified using the Medline database (1977-2000) or by manually searching the Journal of Anesthesia (1987-2000). The clinical characteristics of intraoperative coronary spasm were analyzed in the 56 patients who had developed coronary spasm during non-cardiac surgery.

RESULTS

The mean patient's age was 58 +/- 13 years. The majority of patients were men (75%), Japanese (78%), and had no history of chest pain (75%). Regional anesthesia, vasopressors, alkalosis, hypotension, inadequate depth of anesthesia, and vagal stimulation were noted as major contributing factors. More than half of the patients showed severe hypotension and 30% developed cardiovascular collapse. However, coronary dilators, and nitrates in particular, were very effective for the treatment, and the clinical outcome was relatively good (one death and three cases of myocardial infarction).

CONCLUSIONS

Intraoperative coronary spasm may develop in patients with no history of chest pain. Some of the intraoperative conditions themselves are potent vasoconstricting factors. Once coronary spasm occurs, immediate administration of a full dose of coronary dilators is recommended.

Coronary vasospasm as a possible cause of elevated cardiac troponin I in patients with acute coronary syndrome and insignificant coronary artery disease

BACKGROUND

Abnormal levels of serum cardiac troponin I (cTnI) are occasionally found in patients presenting with acute coronary syndromes but having insignificant coronary artery disease. Before one concludes that an abnormal cTnI level is a false-positive result, the possibility of coronary vasospasm should be considered. This study investigated whether coronary vasospasm could be a reason for elevated cTnI in this patient population.

METHODS AND RESULTS

This investigation enrolled 93 patients who presented to the emergency department with suspected coronary ischemia and had insignificant coronary artery disease. cTnI was elevated in 23 patients (25%) and was normal in 70 patients (75%). Coronary vasospasm, documented by an ergonovine provocation test, was found in 38 patients (41%). Patients with elevated cTnI levels, compared with those with normal cTnI, were older (63 +/- 13 y vs 56 +/- 14 y, P =.032), had a higher incidence of males (78% vs 52%, P =.049) and positive ergonovine provocation tests (74% vs 30%, P <.0001), and tended to have a lower incidence of hypercholesterolemia (26% vs 48%, P =.088) and normal electrocardiograms (48% vs 70%, P =.078). Multivariate analysis showed that the variables independently associated with an elevated cTnI level included coronary vasospasm (odds ratio 2.41, 95% CI 1.48-3.18, P <.0001) and hypercholesterolemia (odds ratio 0.64, 95% CI 0.47-0.99, P =.049). Coronary vasospasm (positive ergonovine provocation test) could explain 74% of elevated cTnI levels in patients with insignificant coronary stenosis.

CONCLUSIONS

In patients with acute coronary syndrome with elevated cTnI and insignificant coronary artery disease, the possibility of coronary vasospasm as a cause of elevated cTnI should be considered.

Stenting for coronary artery spasm

We evaluated coronary stenting in nine patients with clinically severe, angiographically documented spasm refractory to aggressive pharmacologic management. No patient subsequently developed unstable ischemia requiring hospitalization as a consequence of recurrent spasm within the stent. Mechanisms of therapeutic failure included both persistent spasm and spasm in a different artery in one patient. Restenosis occurred in three patients who subsequently underwent repeat revascularization. In the rare, carefully selected patient, stents may represent an adjunct in the management of focal coronary artery spasm, although currently medical therapy remains the standard initial approach.

Intermittent nitrate therapy for prior myocardial infaraction does not induce rebound angina nor reduce cardiac events

OBJECTIVE

Long-term nitrate therapy for ischemic heart disease may cause drug tolerance which diminishes its beneficial effects; consequently, intermittent administration of nitrates is recommended. With this regimen, however, the potential occurrence of rebound angina during the nitrate-free intervals is a source of concern.

SUBJECTS AND METHODS

We carried out a retrospective study of 606 patients to determine whether rebound angina occurred when conventional continuous nitrate administration was replaced by intermittent administration as part of a long-term therapy protocol for prior myocardial infarction. The subjects were receiving treatment for myocardial infarction and included 293 patients treated with nitrates (Nitrate group) and 313 patients who were not (No-nitrate group). The former included 186 patients who received intermittent nitrate administration (Intermittent group) and 107 patients who received continuous administration (Continuous group). The mean period of observation was 4.3 +/- 1.6 months.

RESULTS

There were no cases of rebound angina in the Intermittent group. Cardiac events occurred in one case in the No-nitrate group (0.3%), in 4 cases in the Continuous group (3.7%) and in 2 cases in the Intermittent group (1.1%). The incidence of cardiac events was thus significantly increased in the Continuous group compared to the No-nitrate group (p < 0.05; odds ratio 9.06; 95% CI 1.41-58.28). The Intermittent group did not significantly differ from the No-nitrate group in the incidence of cardiac events.

CONCLUSION

It is concluded that intermittent administration of nitrates does not cause rebound angina and is therefore safe. A randomized controlled trial is needed to find the long-term effect on cardiac events.

Prevalence of migraine and Raynaud's phenomenon in Japanese patients with vasospastic angina

The prevalence of migraine and Raynaud's phenomenon in Japanese patients with vasospastic angina (group I) were compared with those in 2 control groups: one with effort angina (group II) and the other group without known ischemic heart disease (group III). There were no significant differences among the 3 groups with respect to age and sex. The prevalence of migraine in group I was 23 of 100, as compared with 4 of 100 in group II (p<0.01) and 11 of 100 in group III (p<0.05). The prevalence of Raynaud's phenomenon in group I was 9 of 100, as compared with 3 of 100 in group II and 4 of 100 in group III. Thus, in Japan, the prevalence of migraine in patients with vasospastic angina was higher than those in the 2 control groups, whereas the prevalence of Raynaud's phenomenon did not differ significantly among the 3 groups. The prevalence of Raynaud's phenomenon in Japanese patients with vasospastic angina was different from that reported from North America, although the prevalence of migraine was the same. This may be partially explained by racial differences.

Major racial differences in coronary constrictor response between japanese and caucasians with recent myocardial infarction

BACKGROUND

Enhanced coronary vasomotion may contribute to acute coronary occlusion during the acute phase of myocardial infarction (AMI). Japanese have a higher incidence of variant angina than Caucasian patients, but racial differences in vasomotor reactivity early after AMI are controversial.

METHODS AND RESULTS

The same team studied 15 Japanese and 19 Caucasian patients within 14 days of AMI by acetylcholine injection into non-infarct-related (NIRA) and infarct-related (IRA) coronary arteries followed by nitroglycerin. Incidence of vasodilation, vasoconstriction, spasm, and basal tone were assessed in proximal, middle, and distal segments after each drug bolus by quantitative angiography. Japanese patients had much lower cholesterol levels than Caucasians (183+/-59 versus 247+/-53 mg/dL, P<0.006) but showed a lower incidence of vasodilation (2% versus 9% of coronary segments) and a greater incidence of spasm after acetylcholine (47% versus 15% of arteries, P<0.00001). Incidence of spasm was higher in IRAs than in NIRAs in both populations (67% versus 39% and 23% versus 11%, respectively). Multivessel spasm was more common (64% versus 17%, P<0.02) and vasoconstriction of nonspastic segments was greater in Japanese patients (-23.4+/-14.9% versus -20.1+/-15.7%, P<0.02) in the presence of similar average basal coronary tone with respect to post-nitroglycerin dilation and of nonsignificant differences of coronary atherosclerotic score.

CONCLUSIONS

Soon after AMI, Japanese patients exhibited a 3-fold-greater incidence of spasm and greater vasoconstriction of nonspastic segments after acetylcholine than Caucasians. The causes of such differences warrant further investigation because they may have relevant pathophysiological and therapeutic implications.

Coronary artery bypass grafting for spontaneous coronary artery dissection: a case report and a review of the literature

A 37 year-old woman underwent coronary angiography because of chest pain at rest. Selective coronary angiography demonstrated dissection and stenosis with a filling delay from the left main trunk to the left anterior descending coronary artery. The patient was successfully managed with urgent coronary artery bypass grafting. Spontaneous coronary artery dissection is relatively rare and threatens both elderly and young patients with acute coronary disturbances. Patients can be divided etiologically into three groups. The first was comprised of those in the postpartum period. The second was those with atherosclerotic coronary artery disease, and the third was those associated with coronary vasospasm. Dissections are frequently fatal and most of the known cases have been diagnosed at autopsy. Only a few cases have been documented by coronary angiography, and operative cases of spontaneous coronary artery dissection have rarely been reported.

Frequency of provoked coronary vasospasm in patients undergoing coronary arteriography with spasm provocation test of acetylcholine

This study examines the incidence of spasm by intracoronary injection of acetylcholine in Japanese patients who underwent coronary angiography. The subjects were 685 consecutive patients (477 men, mean age 63.2 +/- 7.5 years) who were studied with an acetylcholine test. Acetylcholine was injected in incremental doses of 20, 50, and 80 microg into the right coronary artery and 20, 50, and 100 microg into the left coronary artery. Spasm was defined as total or subtotal occlusion. Coronary vasospasm was determined in 221 patients (32.3%). Spasm occurred often during effort and rest in patients with angina (25 of 51, 49.0%), exertional angina (25 of 74, 33.8%), recent myocardial infarction (30 of 80, 37.5%), healed myocardial infarction (14 of 37, 37.8%), and especially in patients with rest angina (83 of 124, 66.9%), whereas spasm was relatively uncommon in patients with nonischemic heart disease (23 of 252, 9.1%). Spasm was superimposed on significant atherosclerotic lesions in 35.9% of patients as well as on nonfixed atherosclerotic lesions in 30.8% of patients. We conclude that >9% of Japanese patients may have coronary vasospasm with intracoronary injection of acetylcholine and recommend the provocation test for evaluating coronary vasospasm if coronary angiography is undertaken.

In vitro modulation of primate coronary vascular muscle cell reactivity by ovarian steroid hormones

Susceptibility to drug-induced coronary vasospasm in rhesus monkeys increases after removal of the ovaries and can be normalized by adding back physiological levels of estradiol-17ss (E2) and/or natural progesterone (P) in vivo as reported recently by our group. Furthermore, the reactivity status (Ca2+ and protein kinase C responses) of freshly isolated and primary culture coronary artery vascular muscle cells (VMC) mimic the intact coronary artery responses to 5-HT + U46619. Since coronary reactivity is maintained in the isolated VMC, we hypothesized that the reactivity state inherent in the VMC was modulated directly by ovarian steroids in vitro as in the whole animal. To test this hypothesis, we treated hyperreactive VMC from ovariectomized (ovx) monkeys in vitro with E2 or P and measured VMC reactivity to combined stimulation with 5-HT and U46619, as determined by the amplitude and especially the duration of intracellular Ca2+ signals, as well as protein kinase C (PKC) activation/translocation. VMC were treated for 12 96 h with 3 100 pg/ml E2 (10 365 pM) and/or 0.3 3 ng/ml P (0.95 9.5 nM). Hyperreactive responses to the combination of 5-HT and U46619 in untreated VMC were significantly and dose-dependently reduced by treatment in vitro with physiological levels of either E2 or P for at least 24 h. Both the early transient and late sustained increases in intracellular Ca2+ and PKC translocation were blunted, and the effects of 0.2 nM E2 and 3.2 nM P were specifically antagonized by the receptor blockers ICI 182,780 (200 nM) and RU486 (15 nM), respectively. Antibodies to the estrogen receptor and progesterone receptor labeled nuclei in VMC, which were also positively labeled by a smooth muscle myosin heavy chain monoclonal antibody. These data indicate that natural ovarian steroids directly reduce hyperreactive 5-HT and thromboxane A2-stimulated Ca2+ and PKC responses of coronary artery VMC from surgically menopausal rhesus macaques. We hypothesize that vascular hyperreactivity, which may be a critical factor involved in the increased incidence of coronary artery vasospasm and ischemic heart disease in postmenopausal women, can be normalized by E2 and/or P through direct actions on coronary artery vascular muscle cells.

Clinical characteristics in Japanese patients with coexistent hypertrophic cardiomyopathy and coronary vasospasm

There are only a few reports concerning coexistent hypertrophic cardiomyopathy (HCM) and vasospastic angina. Clinical characteristics in patients with both diseases have not been clarified yet. This study was designed to elucidate the relationship between chest pain and coronary vasospasm in HCM patients and to delineate clinical characteristics in patients with both HCM and coronary vasospasm. First, 36 patients with HCM underwent acetylcholine provocation test for coronary vasospasm and were divided into two groups on the basis of presence or absence of coronary vasospasm. Next, the following risk factors for coronary artery disease were compared between the two groups: hypertension, smoking, hyperlipidemia, diabetes mellitus, and hyperuricemia. Coronary vasospasm was induced in 10 (28%) of 36 patients with HCM. There were no significant differences in age and male gender between the two groups. Smoking was more prominent in HCM patients with than without coronary vasospasm (80% vs 35%, p<0.05), but there were no differences in the prevalence of other risk factors between the two groups. In conclusion, coronary vasospasm appears to play a significant role in the etiology of myocardial ischemia in Japanese patients with HCM, and smoking might be a major risk factor for coexistence of HCM and coronary vasospasm.

A psychobehavioral factor, alexithymia, is related to coronary spasm

The aim of this study was to assess whether the psychobehavioral pattern alexithymia is related to coronary artery spasm. Alexithymia, deficient psychological awareness, was examined using the Minnesota Multiphasic Personality Inventory Alexithymia Scale in 100 patients with angina pectoris in whom coronary spasm, defined as > or = 99% coronary narrowing, was documented upon ergonovine provocation, and in 109 patients with chest pain syndrome who were shown to have almost normal coronaries without inducible coronary spasm on coronary angiogram (control group). Alexithymia was approximately twice as prevalent in the coronary spasm group (31%) as in the control group (14%) (p<0.01). Among various conventional risk factors including hyperlipidemia, obesity, diabetes mellitus, hypertension, hyperuricemia, or family history of ischemic heart disease, only male sex and smoking were more prevalent in the coronary spasm group than in the control group (p<0.001). The odds ratios of coronary spasm adjusted for all the other risk parameters including sex and age were 4.14 [95% confidence interval (CI) 1.81-9.47] for alexithymia and 2.38 (95, CI 1.18-4.82) for smoking. A psychobehavioral pattern, alexithymia, relates to coronary spasm. This relationship is independent of the conventional coronary risk factors.

Circadian variation in plasma levels of free-form tissue factor pathway inhibitor antigen in patients with coronary spastic angina

Tissue factor pathway inhibitor (TFPI) is known to inhibit the initial reaction in the tissue factor-mediated coagulation pathway. We measured plasma free-form TFPI antigen levels and monitored 24-h Holter recordings at 06.00, 14.00 and 22.00 h in 15 patients with coronary spastic angina, 13 patients with stable exertional angina, and 11 control subjects. There was a significant circadian variation in plasma free-form TFPI antigen levels in patients with coronary spastic angina (25.8+/-2.0 ng/ml at 06.00 h, 21.1+/-1.6 ng/ml at 14.00 h, and 20.2+/-1.4 ng/ml at 22.00 h; p<0.01). Furthermore, free-form TFPI antigen levels at 06.00 h were significantly higher in coronary spastic angina patients than in patients with stable exertional angina or control subjects (p<0.01). Free-form TFPI antigen levels increased after the ischemic attacks in coronary spastic angina (p<0.01). This circadian variation correlated with the frequency of attacks, with the peak level occurring between midnight to early morning in patients with coronary spastic angina.

The correlation between coronary stenosis index and flow-mediated dilation of the brachial artery

We examined the relationship between flow-mediated dilation (FMD) of the brachial artery and the extent and severity of coronary artery disease (CAD). Using high-resolution ultrasonography, we measured FMD and nitroglycerin-induced brachial artery dilation. We studied 121 patients (77 men, 44 women; mean age 64+/-11 years, range 25-79 years) who underwent coronary arteriography. The extent and severity of CAD were assessed by the coronary stenosis index (CSI). The adjusted FMD correlated inversely with CSI (rs=-0.63, p<0.0001). Multivariate analysis demonstrated that the adjusted FMD was an independent predictor of CSI. The adjusted FMD was 10.2+/-4.8% in patients without CAD (n=32), 7.7+/-6.0% in patients with single-vessel disease (n=31), 5.2+/-5.5% in patients with double-vessel disease (n=29), and 2.0+/-3.9% in patients with triple-vessel disease (n=29). The adjusted FMD was significantly lower in the double- (p<0.01) and triple-vessel (p<0.0001) disease groups than in patients without CAD. The adjusted FMD was significantly lower in the triple-vessel disease group than in the single-vessel disease group (p<0.001). Based on our results, as coronary atherosclerosis becomes more severe, the adjusted brachial artery FMD becomes more severely impaired.

[Coronary spasm--a clinically relevant problem?]

Coronary spasms are defined as reversible coronary stenosis, which limits coronary blood flow under resting conditions. The demonstration of either spontaneous or provoked coronary spasm proves coronary hypercontractility and thus the diagnosis of variant angina. Several stimuli can provoke coronary vasospasm, but the highest sensitivity and specificity has been shown with ergonovine. Alternatively acetylcholine or with less sensitivity, but high specificity, hyperventilation may be employed. Typically coronary vasospasm presents with angina pectoris at rest; the manifestation with myocardial infarction or syncope are of great clinical importance. The prevalence of the disease is unknown due to the rarely performed provocation tests in Western countries. The incidence of positive test results strongly depends on the symptoms of the patients; from 0% in patients without any evidence for myocardial ischemia up to 54% in patients with typical angina at rest have been observed. Coronary vasospasm is closely related to atherosclerotic coronary artery disease, since intravascular ultrasound studies reveal atherosclerotic plaques in almost any spastic segment. Risk factors for coronary artery disease and coronary vasospasm, however, differ profoundly. For the latter cigarette smoking is the only established risk factor. Although several candidates and predisposing factors (serotonin, histamine, thromboxane, endothelin) have been described, the mediators and the pathogenesis of the disease remains unknown. Endothelial dysfunction alone is not sufficient to explain the features of variant angina. Some evidence supports the hypothesis of local inflammation. The mortality in variant angina depends on the extent of the coronary artery disease. Pure coronary vasospasm does not lead to increased mortality; patients with highly active disease presenting with syncope may have an increased risk. Medical treatment should include long-acting calcium antagonists or nitrates, beta-blockers may even favor the occurrence of ischemic attacks. Although the benefit has not been proven, the use of aspirin may considered in highly active disease.

Insulin resistance as an independent risk factor for carotid artery wall intima media thickening in vasospastic angina

Studies have shown the presence of insulin resistance together with compensatory hyperinsulinemia in vasospastic angina as well as obstructive coronary artery disease. There is growing evidence that the development of coronary atherosclerosis may be closely related to systemic atherosclerosis as well as coronary spasm. However, no information is available about the possible relationship between insulin resistance and the existence of carotid atherosclerosis in vasospastic angina without segmental stenosis or luminal irregularities in coronary angiograms. To evaluate the independent effect of insulin resistance on carotid intima media thickening, we performed insulin sensitivity tests (steady-state plasma glucose method) on 40 patients with vasospastic angina and 24 control subjects with angiographically intact coronary arteries. Both oral glucose tolerance tests and lipid analyses were performed. Using B-mode ultrasonography, we assessed intima media thickness and plaque formation of common carotid arteries in these subjects. The steady-state plasma glucose level in the vasospastic angina group was about twofold higher than that of the control group, confirming the presence of insulin resistance in patients with vasospastic angina. The patients with vasospastic angina showed a significant increase in the average intima media thickness of the carotid wall and frequency of plaque formation, although they were comparable to the control subjects in risk factors other than insulin resistance. The intima media thickness was correlated with age (r = .62, P < .001), 2-hour insulin area (r = .45, P < .01), and steady-state plasma glucose level (r = .68, P < .0001) in patients with vasospastic angina. Similar correlations were observed in the control subjects. Multiple regression analyses of data indicated that 67% of the variation in the intima media thickness could be accounted for by age, steady-state plasma glucose level, and cigarette-years in vasospastic angina. In addition, differences in IMT were independently related to vasospastic angina. These results suggest that insulin resistance in association with compensatory hyperinsulinemia may be an important pathogenic factor for the development of coronary artery spasms and systemic early atherosclerosis.