Assessment of coronary spasms with transluminal attenuation gradient in coronary computed tomography angiography.

PURPOSE: To evaluate the imaging features of coronary spasm, including transluminal attenuation gradient (TAG) on coronary computed tomography angiography (CCTA), in patients with vasospastic angina (VA). METHODS: A total of 43 patients with a high clinical likelihood of VA were included in the study. All the subjects underwent double CCTA acquisition: CCTA without a vasodilator ('baseline CT') and CCTA during continuous intravenous nitrate infusion ('IV nitrate CT'). A catheterized ergonovine provocation test was used to determine true VA patients. Coronary spasm is classified into focal- and diffuse-types according to morphological differences. We measured TAG and contrast enhancement of the proximal ostium (ProxHU) of each coronary artery for both the baseline and IV nitrate CT. RESULTS: Twenty-four patients (55.8%) showed positive results of coronary vasospasm on the provocation test. Thirty-eight vessels showed coronary spasms (29.5%): Focal-type in nine vessels (24%), and diffuse-type in 29 (76%). In the baseline CT, LCX showed significantly lower (steeper) TAG in spasm(+) vessels than in spasm(-) vessels, while LAD and RCA showed no significant differences in TAG. The ProxHU of LAD showed significantly lower values in spasm(+) vessels than in spasm(-) vessels, while the other vessels did not show significant differences in ProxHU. For IV nitrate CT, there were no significant differences in either the TAG and ProxHU between spasm(+) and (-) vessels for all the three vessel types. In subgroup analysis for spasm(+) vessels, diffuse spasms showed significantly lower TAG than focal spasms, while the ProxHU did not differ between the two types of spasm. CONCLUSIONS: A relatively large percentage of coronary spasms present as diffuse type, and the TAG values significantly differed according to the morphological type of the coronary spasm.

Differential prognosis of vasospastic angina according to presentation with sudden cardiac arrest or not: Analysis of the Korean Health Insurance Review and Assessment Service.

BACKGROUND: The long-term prognosis of vasospastic angina (VSA) patients presenting with aborted sudden cardiac death (ASCD) is still unknown. We sought to compare the long-term clinical outcomes between VSA patients presenting with and without ASCD by retrospective analysis of a nationwide population-based database. METHODS: A total of 6972 patients in the Health Insurance Review and Assessment database who were hospitalized in the intensive care unit with VSA between July 1, 2007 and May 31, 2015 were enrolled. Primary outcome was the composite of cardiac arrest and acute myocardial infarction after discharge. RESULTS: Five hundred ninety-eight (8.6%) VSA patients presented with ASCD. On inverse probability of treatment weighting, ASCD patients had a significantly increased risk of the composite of cardiac arrest and acute myocardial infarction (adjusted hazard ratio, 2.52; 95% confidence interval, 1.72-3.67; p < 0.001) during the median follow-up duration of 4 years. The association of ASCD presentation with a worse outcome in terms of primary outcome was consistent across various subgroups, including comorbidity type and use of vasodilators (all p-values for interaction: non-significant). ASCD patients treated with an implantable cardioverter defibrillator (ICD) had a lower incidence of the composite of cardiac arrest and acute myocardial infarction during follow-up than those without an ICD (p = 0.009). CONCLUSIONS: VSA patients that present with ASCD are at increased risk of cardiac arrest or myocardial infarction during long-term follow-up despite adequate vasodilator therapy. An ICD is a potential therapeutic option for secondary prevention.

Renal Denervation in Patients with Resistant Hypertension-Assessment by 3T Renal 23Na-MRI: Preliminary Results.

BACKGROUND/AIM: Renal denervation (RDN) has been considered a promising therapy option for patients suffering from therapy-resistant hypertension. Besides, in blood-pressure regularization, the kidneys play a fundamental role in sodium ((23)Na) homeostasis. This study assesses the effect of RDN on renal (23)Na concentration using (23)Na magnetic resonance imaging (MRI). PATIENTS AND METHODS: Two patients with therapy-resistant hypertension underwent RDN. (23)Na-MRI, (1)H-MRI, including diffusion weighted imaging (DWI), as well as endothelial dysfunction assessment, were performed 1 day prior, as well as 1, 30 and 90 days after RDN. RESULTS: The renal corticomedullary (23)Na gradient did not change after RDN for all time points. Additionally, functional imaging and retinal vessel parameters were not influenced by RDN. Results regarding blood pressure changes and arterial stiffness, as well as patients' clinical outcome, were heterogeneous. CONCLUSION: RDN does not seem to alter renal (23)Na concentration gradients, as measured by MRI.

In vivo assessment of ergonovine-induced coronary artery spasm by 64-slice multislice computed tomography.

BACKGROUND: The potential of multislice CT (MSCT) to predict coronary spasm has not been elucidated. The aim of this study was to investigate whether the morphological features observed on MSCT at the site of ergonovine-induced epicardial spasm could be used as diagnostic criteria for coronary spasm. METHODS AND RESULTS: A total of 296 plaques in 199 patients with clinically suspected coronary spastic angina without coronary stenosis (<75%) who underwent invasive angiography with intravenous ergonovine provocative testing were analyzed by MSCT. Calcification, CT attenuation, and patterns of vascular remodeling were evaluated in each plaque by MSCT. Plaques were divided into spasm group or nonspasm group based on the results of the ergonovine provocative test. On a per-plaque basis, noncalcified plaques were more frequently observed in the spasm group (96% versus 20%, P<0.01). Intermediate attenuation plaques (CT density ≥53.8 Hounsfield units identified by receiver operating characteristic analysis) were more common in the spasm group (93% versus 28%, P<0.01), as was negative remodeling (67% versus 11%, P<0.01). Multivariable analysis revealed noncalcified (odds ratio [OR], 48.7; 95% CI, 8.81-269; P<0.01), intermediate attenuation (OR, 19.3; 95% CI, 4.96-75.4; P<0.01); negative remodeling (OR, 8.83; 95% CI, 2.87-27.2; P<0.01); and male sex (OR, 4.55; 95% CI, 1.24-16.6; P=0.02) as predictors of the plaque associated with coronary spasm. CONCLUSIONS: MSCT can detect differences in individual plaque composition and morphology among atherosclerotic plaques without significant luminal narrowing in areas of inducible vasospasm compared to areas without vasospasm.

Spinal cord stimulation for refractory angina pectoris: a retrospective analysis of efficacy and cost-benefit.

BACKGROUND: Patients with refractory angina pectoris have severe symptoms despite optimal medication, but are not suitable for revascularisation. Spinal cord stimulation (SCS) has been used for treating refractory angina pectoris since 1985. The efficacy of SCS has been proven by randomised controlled trials and follow-up studies have shown that SCS is a safe treatment. The objective of the current study was to retrospectively analyse the clinical outcomes and cost-benefit of SCS in patients with refractory angina pectoris. METHODS: Eighteen months after SCS implantation, the effects on Canadian Cardiovascular Society (CCS) functional level and acute symptom relief of 24 patients with permanent SCS were analysed by review of medical records. Nineteen of these 24 patients were able to report their anginal frequency, nitroglycerin consumption and subjective perception on physical activity and quality of life. RESULTS: Angina frequency decreased from a median of 14.0 to 2.3 attacks/week (p < 0.01). Nitroglycerin intake decreased from a median of 27.5 to 1.5 doses/week (p < 0.01). Canadian Cardiovascular Society angina class improved from a median of three to two (p < 0.001). During a three-year period before SCS implantation, the hospitalisation rate and duration related to coronary artery disease increased progressively. The duration of hospitalisation increased from a median of three to 10 days/patient/year. In the year after SCS implantation the duration of hospitalisation decreased to a median of 0 day/patient/year (p < 0.001). The cost of hospital care due to coronary artery disease decreased significantly thereafter. The total cost of SCS procedure was recovered within 16 months after implantation, which is less than 40% of the device life span. CONCLUSIONS: This retrospective study indicates that SCS treatment alleviates angina symptoms and improves quality of life. The treatment is also effective in preventing hospitalisations and saving costs in hospital care. A prospective study is warranted to confirm the current observations.

Noninvasive assessment of coronary artery disease by multislice spiral computed tomography using a new retrospectively ECG-gated image reconstruction technique.

The present study was designed to investigate the accuracy of multislice spiral computed tomography (MSCT) in detecting coronary artery disease, compared with coronary angiography (CAG), using a new retrospectively ECG-gated reconstruction method that reduced cardiac motion artifact. The study group comprised 54 consecutive patients undergoing MSCT and CAG. MSCT was performed using a SOMATOM Volume Zoom (4-detector-row, Siemens, Germany) with slice thickness 1.0 mm, pitch 1.5 (table feed: 1.5 mm per rotation) and gantry rotation time 500 ms. Metoprolol (20-60 mg) was administered orally prior to MSCT imaging. ECG-gated image reconstruction was performed with the reconstruction window (250 ms) positioned immediately before atrial contraction in order to reduce the cardiac motion artifact caused by the abrupt diastolic ventricular movement occurring during the rapid filling and atrial contraction periods. Following inspection of the volume rendering images, multiplanar reconstruction images and axial images of the left main coronary artery (LMCA), left anterior descending artery (LAD), left circumflex artery (LCx) and right coronary artery (RCA) were obtained and evaluated for luminal narrowing. The results were compared with those obtained by CAG. Of 216 coronary arteries, 206 (95.4%) were assessable; 10 arteries were excluded from the analysis because of severe calcification (n=4), stents (n=3) or insufficient contrast enhancement (n=3). The sensitivity to detect coronary stenoses >or=50% was 93.5% and the specificity to define luminal narrowing <50% was 97.2%. The positive predictive value and the negative predictive value were 93.5% and 97.2%, respectively. The sensitivity was still satisfactory (80.6%) even when non-assessable arteries were included in the analysis. The new retrospectively ECG-gated reconstruction method for MSCT has excellent diagnostic accuracy in detecting significant coronary artery stenoses.

Assessment of the vasomotility of epicardial coronary arteries with quantitative coronary angiography.

Quantitative in vivo analysis of the vasomotility of epicardial coronary arteries is based on the measurement of changes of the vessel diameters. Vessel contours can be determined with the help of a precision caliper by the investigator or with computer-assisted geometrical analysis systems applying a contour detection algorithm; the variability of the results from repeated coronary diameter measurements in the identical film frame is comparably low with all systems (less than or equal to 0.12 mm standard deviation). When investigating the influence of an intervention on coronary vasomotility the variability of the measurements can only be kept low by careful standardization of the entire method. Repeated coronary angiograms are performed in identical angiographic projections (mono- or biplane) with standardization of the inspiratory status of the patient and of the rate of contrast material injection (automatic injection pump). For quantitative analysis all coronary segments with a diameter greater than 1 mm which are clearly outlined, free from overlaps, and mainly run parallel to the image plane, are selected by the investigator in preferably end-diastolic cineframes. Whereas with a caliper and with most of the semi-automatic edge detection systems the segment diameter can only be measured at particular sites defined by the investigator, few systems are able to analyze and average the diameter over the entire segment length. The variability of measurements of the minimal diameters of coronary stenoses in different cine frames is particularly high; therefore, only distinct changes of this parameter (e.g. with the CAAS-system greater than 0.24 mm) may be considered significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of radionuclide ventriculography in assessment of coronary artery spasm.

Provocative tests that permit detection of coronary artery spasm are widely used in patients with ischemic syndromes. To assess the usefulness of radionuclide ventriculography combined with provocative tests for diagnosis of coronary spasm, the left ventricular (LV) response to exercise, hyperventilation and a cold pressor test was determined in 3 groups. Group I included 10 normal subjects; group II, 49 patients with typical effort angina and fixed obstructive coronary artery disease at catheterization; and group III, 19 patients suspected of having vasospastic angina based on clinical and electrocardiographic findings, each of whom had normal coronary angiographic findings. In group I, LV ejection fraction (EF) increased during hyperventilation and exercise testing in 9 of 10 subjects (90%) and failed to decrease 5% in 9 of 10 subjects (90%) during cold testing. In contrast, while 18 of 49 patients (37%) of group II showed LV dysfunction with cold testing and 8% with hyperventilation, all showed abnormal LV function during exercise. Finally, in group III, LVEF increased during exercise, mimicking the response in normal group, while dysfunction was present in 14 of 19 (74%) during hyperventilation and in 17 of 19 (89%) during cold testing. When results of hyperventilation and cold testing were combined, abnormal responses were present in all patients. Thus, radionuclide ventriculography, when performed in association with 3 forms of stress--exercise, hyperventilation and cold testing--allows accurate identification of patients likely to have coronary spasm.

Clinical characteristics of coronary artery spasm: electrocardiographic, hemodynamic and arteriographic assessment.

We studied the clinical characteristics of 153 patients with angina pectoris associated with coronary artery spasm (CAS). The study was designed to investigate the relationship of CAS to ST segment deviation and to the site of fixed stenosis, and hemodynamic alteration during a spastic event. Analysis of coronary arteriograms and multilead electrocardiograms obtained simultaneously from 170 events of CAS by the use of radioluscent carbon-fiber electrodes resulted in 58 events with ST elevation which were related to total occlusion of major coronary arteries due to CAS; another 54 events with ST depression, in which the affected coronary arteries demonstrated severe but incomplete occlusion, or total occlusion but were visualized via collateral vessels; and remaining 58 events without ST deviation showing mild occlusion. The results indicate a close correlation between magnitude of CAS and ST segment deviation. CAS occurred at the site of pre-existing fixed stenosis including minor plaque defect in 133 patients and at apparently normal site in 20 patients. In the former group, only four patients had triple vessel disease, while 95 had nonsignificant fixed lesion. In the latter group, 10 patients had minor lesion distant from the site of CAS. Thus, CAS is closely related to fixed stenosis, which may have but a limited role as a cause of CAS. Hemodynamic measurements during spastic events were obtained from 49 patients including 41 events with spasm of the left anterior descending artery (LAD) and 21 events with spasm of the right coronary artery (RCA). The onset of an increase in left ventricular (LV) filling pressure and a reduction in LV dP/dt preceded ST segment deviation in all events. The first hemodynamic variable manifested in the spastic event was the reduction of LV contraction dP/dt in the majority of patients. The increase of LV filling pressure was greater in LAD spasm than RCA spasm (11 +/- 6 mmHg vs 7 +/- 4 mmHg, P less than 0.0125) and in events with ST elevation than with ST depression (11 +/- 5 mmHg vs 6 +/- 5 mmHg, p less than 0.001). Right ventricular functional impairment was mild in most patients during CAS. The study indicates that mechanical impairment precedes electrical impairment during CAS and that LAD spasm with ST elevation represents the most severe LV dysfunction.

Value of noninvasive assessment of patients with atypical chest pain and suspected coronary spasm using ergonovine infusion and thallium-201 scintigraphy.

Twenty-six patients with known benign coronary anatomic characteristics and atypical chest pain syndromes were evaluated for the possibility of coronary spasm. Incremental intravenous ergonovine maleate infusions were administered, and thallium-201 scintigraphy was performed at the peak dosage and during recovery in the coronary care unit. With ergonovine therapy, 4 patients (16%) had chest pain associated with electrocardiographic (ECG) or scintigraphic changes. Nine patients (35%) had chest pain without associated ECG or scintigraphic changes, and 13 patients did not have chest pain in response to ergonovine administration, although 2 (8%) had ergonovine-induced scintigraphic defects. All 4 patients with ergonovine-induced chest pain and associated ECG or scintigraphic abnormalities had resolution or reduction of chest pain after medical treatment. However, 7 of the 9 patients with ergonovine-induced chest pain in the absence of ECG or scintigraphic abnormalities continued to have symptoms despite medical treatment a mean of 18 months later. In this limited study of a select group, bedside ergonovine provocation appeared safe. Many patients had chest pain, but few showed ECG or scintigraphic evidence of ischemia. Perfusion scintigraphy appears to have potential complementary value for the identification of an ischemic cardiac cause of atypical chest pain and provides a rationale for appropriate therapy.

Therapeutic and economic value of a normal coronary angiogram.

A significant number of patients with severe angina or intractable atypical chest pain referred for coronary arteriography are found to have normal coronary vessels. To determine what therapeutic or economic benefit may be derived from these studies, we analyzed the data of 72 consecutive patients with normal vessels referred for cardiac catheterization because of severe chest pain. The clinical status and hospitalizations were analyzed for the 2 year period before and the 2 year period after angiography. There were no deaths or myocardial infarctions. Although 47 were thought to have angina and 25 atypical pain before catheterization, the chest pain was reclassified with only 15 continuing to have anginal pain, 40 atypical pain, and 17 no pain. Functional improvement by at least one New York Heart Association class occurred in 74 percent of patients with 36 (50 percent) having no functional limitation. The use of cardiac medications was also significantly reduced. Despite functional improvement, no change in employment states could be demonstrated. The use of medical facilities was significantly less, the average number of hospital days per patient declining from 17 to 3.9 and hospitalization decreasing from 1.5 to 0.4. The result was a significant decrease in estimated hospital costs. We conclude that in patients referred for coronary angiography for severe chest pain, documentation of a normal coronary arteriogram significantly alters the clinical assessment of symptoms, improves functional status, modifies medical therapy, and reduces hospitalization and medical costs. These therapeutic and economic benefits deserve consideration in the evaluation of coronary angiography for its overall effectiveness.