Pathogenesis and Traditional Chinese Medicine Prevention and Treatment Strategy of Refractory Angina Based on Theory of Stasis and Toxin / 中国实验方剂学杂志

Refractory angina is characterized by recurrent and persistent angina with a duration of not less than three months， which is related to reversible ischemia and hypoxia caused by coronary stenosis and obstruction. It mainly involves obstructive coronary artery disease and non-obstructive coronary artery disease with coronary artery spasm and coronary microvascular dysfunction. “Stasis and toxin” play an important role in the pathogenesis of cardiovascular diseases. The pathogenesis of stasis and toxin is stubborn filthy turbidity featured by slow accumulation and sudden onset，and rapid changes，which coincides with the characteristics of refractory angina which is complex and changeable，prolonged and difficult to cure. The pathogenesis of refractory angina involves a combination of underlying deficiency and excessive manifestation， with "stasis and toxin" playing a crucial role as an important pathological factor in the whole process of refractory angina. Traditional Chinese medicine （TCM） employs a holistic approach known as "activating blood circulation and removing toxins"， which is supplemented by various methods to tonify Qi and warm Yang， nourish the kidneys and invigorate the spleen， clear heat and transform phlegm. This approach applies anti-inflammatory measures， regulates lipid metabolism， inhibits oxidative stress and thrombus formation， protects endothelial function in blood vessels， as well as establishes collateral circulation for the prevention and treatment of refractory angina. Therefore，based on the theory of "stasis and toxin"，combined with TCM theory and modern medical research，this paper discusses the pathogenesis of refractory angina and the prevention and treatment strategy of TCM，and elucidates the reasons for the difficulty in curing refractory angina and the relationship between refractory angina and common angina pectoris，coronary microvascular dysfunction，coronary artery spasm and obstructive coronary artery disease，hoping to provide certain theoretical basis and clinical ideas for the prevention and treatment of refractory angina with TCM.

Unexplained Syncope With the λ Pattern in Electrocardiogram:a Case Report / 中国循环杂志

The λ pattern is a rare electrocardiogram feature in clinical practice,which often indicates the occurrence of impending fatal ventricular tachyarrhythmias or sudden cardiac death.In this case,Holter monitoring recorded a progressive evolution of the λ pattern followed by advanced atrioventricular blocks in a patient with chest pain accompanied by syncope.λ sign occurred at the time of chest pain,and advanced atrioventricular blocks were recorded at the time of subsequent syncope.Coronary stenosis was detected in the left circumflex by coronary angiography.The patient recovered after stent implantation in the culprit vessel and related medications to prevent coronary spasm.Our case indicate that the λ pattern could occur prior advanced atrioventricular blocks-induced syncope in patient with ischemic heart disease.

Ventricular tachycardia and acute myocardial infarction induced by coronary artery spasm in patient without coronary artery disease

Coronary artery spasm, marked by coronary vasoconstriction, is one of the etiologies of myocardial ischemia, often presenting as vasospastic angina. Vasospastic angina is diagnosed when angina which predominantly occurs at rest, is accompanied by ST-segment changes in ECG, or in the setting of borderline ECG changes, a positive provocation test through coronary angiography is required. Although coronary artery spasms could manifest in wide clinical settings, the occurrence of ventricular arrhythmias and acute myocardial infarction solely caused by spasms without evidence of prior coronary artery disease is rare. This case report is about a 46-year-old man who presented with ventricular tachycardia and acute myocardial infarction that later was found to be secondary to coronary vasospasm observed directly through coronary angiography. We aim to emphasize the importance of coronary artery spasms as the etiology of malignant ventricular arrhythmias and acute myocardial infarction manifestation. Optimization in treatment and prevention shall reduce future life-threatening complications of coronary artery spasms.

Impact of drug-eluting stent-associated coronary artery spasm on 3-year clinical outcomes: A propensity score matching analysis

Background: It has been reported that significant endothelial dysfunction or clinically evident vasospasm can be associated with drug-eluting stents (DESs). However, the impact of DES associated coronary artery spasm (CAS) on long-term clinical outcomes has not been fully elucidated as compared with those of patients with vasospastic angina. Methods: A total of 2797 consecutive patients without significant coronary artery lesion (<70%), who underwent the Acetylcholine (Ach) provocation test, were enrolled between Nov 2004 and Oct 2010. DES-associated spasm was defined as significant CAS in proximal or distal to previously implanted DES site at follow-up angiography with Ach test. Patients were divided into two groups (DES-CAS; n ¼ 108, CAS; n ¼ 1878). For adjustment, propensity score matching (PSM) was done (C-statistics ¼ 0.766, DESCAS; n ¼ 102, CAS; n ¼ 102). SPSS 20 (Inc., Chicago, Illinois) was used to analyze this data. Results: Baseline characteristics were worse in the DES-CAS group. After PSM, both baseline characteristics and the Ach test results were balanced except higher incidence of diffuse CAS and ECG change in the DES-CAS group. During Ach test, the incidence of diffuse spasm (93.1% vs. 81.3%, p ¼ 0.012) and ST-T change (10.7% vs. 1.9%, p ¼ 0.010) were higher in the DES-CAS group. At 3-year, before and after adjustment, the DES-CAS group showed a higher incidence of coronary revascularization (9.8% vs. 0.0%, p ¼ 0.001), recurrent chest pain requiring follow up coronary angiography (CAG, 24.5% vs. 7.8%, p ¼ 0.001) and major adverse cardiac events (MACEs, 9.8% vs. 0.9%, p < 0.005). Conclusion: In this study, DES associated CAS was associated with higher incidence of diffuse spasm, ST-T change and adverse 3-year clinical outcomes. Special caution should be exercised in this particular subset of patients.

Impact of Insulin Resistance on Acetylcholine-Induced Coronary Artery Spasm in Non-Diabetic Patients

PURPOSE: Coronary artery spasm (CAS) and diabetes mellitus (DM) are implicated in endothelial dysfunction, and insulin resistance (IR) is a major etiological cause of type 2 DM. However, the association between CAS and IR in non-diabetic individuals has not been elucidated. The aim of the present study was to evaluate the impact of IR on CAS in patients without DM. MATERIALS AND METHODS: A total of 330 eligible patients without DM and coronary artery disease who underwent acetylcholine (Ach) provocation test were enrolled in this study. Inclusion criteria included both hemoglobin A1c < 6.0% and fasting glucose level < 110 mg/dL without type 2 DM. Patients were divided into quartile groups according the level of homeostasis model assessment of insulin resistance (HOMA-IR): 1Q (n=82; HOMA-IR < 1.35), 2Q (n=82; 1.35≤HOMA-IR < 1.93), 3Q (n=83; 1.93≤HOMA-IR < 2.73), and 4Q (n=83; HOMA-IR≥2.73). RESULTS: In the present study, the higher HOMA-IR group (3Q and 4Q) was older and had higher body mass index, fasting blood glucose, serum insulin, hemoglobin A1c, total cholesterol, and triglyceride levels than the lower HOMA-IR group (1Q). Also, poor IR (3Q and 4Q) was considerably associated with frequent CAS. Compared with Q1, the hazard ratios for Q3 and Q4 were 3.55 (95% CI: 1.79–7.03, p < 0.001) and 2.12 (95% CI: 1.07–4.21, p=0.031), respectively, after adjustment of baseline risk confounders. Also, diffuse spasm and accompanying chest pain during Ach test were more strongly associated with IR patients with CAS. CONCLUSION: HOMA-IR was significantly negatively correlated with reference diameter measured after nitroglycerin and significantly positively correlated with diffuse spasm and chest pain.

Resuscitated cardiac arrest caused by coronary artery spasm after coronary artery bypass grafting: A case report-

We report successful resuscitation of a patient after cardiac arrest on postoperative day 4 after coronary artery bypass grafting (CABG). The patient underwent proximal right coronary artery stent insertion 1 year preceding his CABG, and in-stent restenosis of the stent was found on coronary angiography (CAG). CABG was planned. The patient was treated with a nitroglycerin (NTG) for chest pain, and in the holding area of the operating theater, his chest pain resumed during brief cessation of the NTG while changing the syringe pump. Intraoperatively, normal flow was confirmed at the graft site with flowmetry, while the patient received a NTG infusion. On postoperative day 4, the patient developed chest pain and a subsequent cardiac arrest. He was resuscitated with chest compressions alone, and emergent CAG was performed. It showed coronary artery spasm of the left anterior descending coronary artery, confirmed by provocation testing. The patient was discharged with symptoms well controlled on oral medications.

Impact of Cigarette Smoking: a 3-Year Clinical Outcome of Vasospastic Angina Patients

BACKGROUND AND OBJECTIVES: Cigarette smoking is a risk significant factor in coronary artery disease (CAD) and vasospastic angina (VSA). However, it is largely unknown whether smoking adds to any long-term clinical risk in VSA patients. SUBJECTS AND METHODS: A total of 2797 patients without significant CAD underwent acetylcholine (Ach) provocation test between November 2004 and October 2010. Patients were divided into three groups, based on the presence of coronary artery spasm (CAS) and smoking habits (non-CAS group: n=1188, non-smoking CAS group: n=1214, smoking CAS group: n=395). All CAS patients were prescribed with anti-anginal medications for at least 6 months. The incidence of major clinical outcomes and recurrent angina of these groups were compared up to 3 years. RESULTS: There were considerable differences in the baseline clinical and angiographic characteristics among the three groups, but there was no difference in the endpoints among the three groups (including individual and composite hard endpoints) such as death, myocardial infarction, de novo percutaneous coronary intervention, cerebrovascular accident, and major adverse cardiac events. However, there was a higher incidence of recurrent angina in both the non-smoking CAS group and smoking CAS group, as compared to the non-CAS group. In multivariable adjusted Cox-proportional hazards regression analysis, smoking CAS group exhibited a higher incidence of recurrent angina compared with the non-CAS group (hazard ratio [HR]; 2.46, 95% confidence interval [CI]; 1.46-4.14, p=0.001) and non-smoking CAS group (HR; 1.76, 95% CI; 1.08-2.87, p=0.021). CONCLUSION: Cigarette smoking CAS group exhibited higher incidence of recurrent angina during the 3-year clinical follow-up compared with both the non-CAS group and non-smoking CAS group. Quitting of smoking, paired with intensive medical therapy and close clinical follow-up, can help to prevent recurrent angina.

Recurrent myocardial infarction secondary to Prinzmetal's variant angina

Prinzmetal's variant angina describes chest pain secondary to reversible coronary artery vasospasm in the context of both diseased and non-diseased coronary arteries. Symptoms typically occur when the patient is at rest and are associated with transient ST-segment elevation. Acute episodes respond to glyceryl trinitrate, but myocardial infarction and other potentially fatal complications can occur, and long-term management can be challenging. Although it is not well understood, the underlying mechanism appears to involve a combination of endothelial damage and vasoactive mediators. In this case, a 35-year-old woman with myocardial infarction secondary to coronary artery vasospasm experienced recurrent chest pain. Coronary angiography revealed severe focal stenosis in the mid left anterior descending artery, which completely resolved after administration of intracoronary glyceryl trinitrate. The patient was discharged on nitrates and calcium channel blockers. The patient re-presented with another myocardial infarction, requiring up-titration of medical therapy.

Case Reports of Severe Coronary Artery Spasm Associated with Three Different Endocrine Hyperfunction

Disorders of the endocrine system including hormone hyperfunction and hypofunction have multiple effects on cardiovascular system. However, in clinical practice, there are many cases of delayed or overlooked diagnosis of underlying endocrine dysfunction in patients presenting chest pain or other cardiac symptoms. Herein, we report three cases of endocrine hyperfunction presenting as coronary spasm; Graves' hyperthyroidism, pheochromocytoma, and primary hyperparathyroidism. Chest pains disappear after treatment for these endocrine diseases. Endocrine hyperfunctions such as the three cases described above should be considered as possible diagnosis in patients with complaint of chest pain. High index of suspicion are needed.

Cardiac arrest due to coronary spasms in a patient in a lateral decubitus position and contralateral thoracotomy state during Ivor Lewis esophagogastrectomy: A case report

A coronary artery spasm (CAS) during noncardiac surgery is rare, but it can lead to catastrophic consequences. Furthermore, cardiac arrest caused by CAS, while a patient is in a lateral decubitus position and under contralateral thoracotomy conditions, represents a major challenge to both the anesthesiologist and the surgeon. We present a case of cardiac arrest due to CAS in a 69-year-old man undergoing Ivor Lewis esophagogastrectomy surgery for esophageal cancer in the left lateral decubitus position and the right thoracotomy state. The patient was successfully resuscitated with conventional cardiopulmonary resuscitation after repositioning him to a supine position.

Cardiac arrest due to coronary spasms in a patient in a lateral decubitus position and contralateral thoracotomy state during Ivor Lewis esophagogastrectomy: A case report

A coronary artery spasm (CAS) during noncardiac surgery is rare, but it can lead to catastrophic consequences. Furthermore, cardiac arrest caused by CAS, while a patient is in a lateral decubitus position and under contralateral thoracotomy conditions, represents a major challenge to both the anesthesiologist and the surgeon. We present a case of cardiac arrest due to CAS in a 69-year-old man undergoing Ivor Lewis esophagogastrectomy surgery for esophageal cancer in the left lateral decubitus position and the right thoracotomy state. The patient was successfully resuscitated with conventional cardiopulmonary resuscitation after repositioning him to a supine position.

Coronary artery spasm following intravenous phenylephrine on a patient under general anesthesia with previously undiagnosed variant angina and successful treatment by nitroglycerin: A case report

Coronary artery spasm under general anesthesia induces interruption of blood flow of coronary arteries and can be detected by a sudden ST elevation on electrocardiogram, which may be followed by severe cardiovascular complications. We have experienced a case of a sudden ST elevation on a 52-year-old patient with no history of coronary artery diseases undergoing spine surgery under general anesthesia. Following administration of nitroglycerin, ST elevation returned to normal. Postoperative coronary angiogram showed positive on ergonovine provocation test and the patient was diagnosed as variant angina. Correlating with the results, we concluded that the ST elevation was probably due to coronary artery spasm. Although the definite mechanism of the coronary artery spasm is unclear. A-adrenergic stimulation by phenylephrine may have acted as a solitary factor or as one of many factors. Early administration of nitroglycerin and calcium channel blocker seems to be useful in treatment and prevention of recurrence.

Atropine injection followed by coronary artery spasm with ventricular tachycardia during spinal anesthesia: A case report / 대한마취과학회지

Bradycardia may occur during spinal anesthesia with atropine commonly used as a treatment. A 44-year-old female with no known history of any underlying diseases, developed a coronary spasm following ventricular tachycardia when 0.5 mg of atropine was injected intravenously to treat bradycardia during spinal anesthesia. The imbalance caused by atropine in the sympathovagal activity may predispose the coronary artery to develop spasms with ventricular tachycardia. Therefore prudent use of atropine should be accompanied by close monitoring.

The Impact of High Sensitivity C-Reactive Protein Level on Coronary Artery Spasm as Assessed by Intracoronary Acetylcholine Provocation Test

PURPOSE: High sensitive C-reactive protein (hs CRP) is well known as a strong risk factor of cardiovascular disease (CVD). The aim of this study is to evaluate the impact of elevated hs CRP on coronary artery spasm (CAS) as assessed by intracoronary acetylcholine (ACh) provocation test. MATERIALS AND METHODS: A total of 1729 consecutive patients without significant CVD who underwent coronary angiography and intracoronary ACh test between November 2004 and August 2010 were analyzed. The patients were divided into five groups according to quintiles of hs CRP levels. RESULTS: At baseline, the prevalence of elderly, hypertension, diabetes mellitus, current smoking, and lipid levels were higher in patients with higher hs CRP. During ACh test, the incidences of significant CAS, ischemic electrocardiography (EKG) change, multivessel, and diffuse CAS were higher in patients with higher hs CRP. Multivariate analysis showed that the old age (OR=1.01, CI; 1.0-1.02, p=0.0226), myocardial bridge (OR=3.34, CI; 2.16-5.17, p<0.001), and highest quintile hs CRP (OR=1.54, CI; 1.12-2.18, p=0.008) were independent predictors of ACh induced CAS. However, there was no difference in clinical outcomes up to 12 months. CONCLUSION: In conclusion, higher hs CRP was associated with higher incidence of CAS, worse angiographic characteristics and ischemic EKG change, but was not associated with clinical outcomes.

The relationship between thyroid dysfunction and coronary artery disease--A respective analysis and literature review / 中国综合临床

Objective To study the relationship between the thyroid dysfunction and coronary artery disease (CAD). Methods Two thousands and twelve patients,diagnosed as CAD by coronary angiography from January 2003 to February 2010 in Peking Union Hospital,were enrolled into this study and divided into normal thyroid function, hyperthyroidism, and hypothyroidism groups. The thyroid function data and the coronary angiography findings were compared among three groups. Results The incidence rates of hypertension (40%vs. 69. 4% vs. 78.6%, x2 = 12. 331, P = 0. 01) and hyperlipemia(20. 0% vs. 67.4% vs. 85.7%, x2 =12. 331 ,P=0. 002) in hyperthyroidism patients were significantly lower than normal thyroid function patients and hypothyroidism patients, but no significant differences were found in the comparison of diabetes incidence rates among three groups (20. 0% vs. 41.6% vs. 35.7%, x2 = 2. 114,P =0. 347). According to the coronary angiography findings, we found that the incidence rate of CAD of hypothyroidism patients was higher than hyperthyroidism patients(71.0% vs. 55. 2%, x2. = 1. 804, P = 0. 179), but the difference didn' t reach statistically significant level. Two hyperthyroidism patients had coronary artery spasm and acute myocardial infarction. Conclusion Hypothyroidism had more promotion effect on coronary artery disease than hyperthyroidism,but higher serum thyroxin level increased the risk of coronary spasm and the probability of acute myocardial infarction,which could be well adjusted by medication treatment.

Vasoespasmo coronario asintomático y arritmias ventriculares graves / Asymptomatic Coronary Artery Spasm and Severe Ventricular Arrhythmias

El vasoespasmo coronario generalmente evoluciona con episodios de dolor torácico y elevación del ST. No obstante, existen casos de vasoespasmo sin dolor torácico con taquiarritmias ventriculares documentadas. Su incidencia se desconoce y debe incluirse en el diagnóstico diferencial de taquicardia o fibrilación ventricular idiopática. En esta presentación se describe el caso de un paciente con historia de dos cuadros sincopales sin cardiopatía estructural aparente. La monitorización electrocardiográfica continua objetivó episodios de elevación del ST que conducían a taquicardia ventricular polimorfa. Con el diagnóstico de vasoespasmo coronario asintomático se inició tratamiento con calcioantagonistas y se implantó un cardiodesfibrilador automático.

Coronary artery spasm usually results in episodes of chest pain and ST-segment elevation. However, it may occasionally occur in the absence of angina with documented severe ventricular arrhythmias. The incidence of this condition is unknown and should be included in the differential diagnosis of idiopathic ventricular tachycardia or fibrillation. We describe the case of a patient with a history of two episodes of syncope without apparent structural heart disease. Continuous ECG monitoring revealed the presence of episodes of ST-segment elevation leading to polymorphic ventricular tachycardia. Asymptomatic coronary artery spasm was diagnosed and treatment with calcium channel blockers was initiated; an implantable cardioverter defibrillator device was implanted.

High fever, coronary artery spasm and convulsion associated with prostaglandin E2 in atonic uterine bleeding / 대한산부인과학회지

Postpartum hemorrhage is a serious condition related with maternal morbidity and mortality. Prior to surgical treatment, oxytocin and prostaglandin analogs administration are common. Pyrexia after prostaglandin E1 was well known, but PG E2 has been shown to have a few complication even though coronary arterial spasm was rarely reported. The 38-year old woman who delivered 3rd baby by Cesarean section was developed the atonic uterine bleeding. During the treatment with high dose sulprostone (PG E2), she complained the anterior chest pain, her body temperature was elevated to 41.2 degrees C, and then convulsion with stuporous mentality was developed. EKG revealed inverted T wave in II. III, aVF lead, and CK-MB, troponin I was elevated. The laboratory test revealed elevated SGOT/SGPT, myoglobin, and metabolic acidosis. But CSF study, blood culture, direct/indirect Coomb's test, brain CT, and echocardiography were all negative. After supportive care, she came to be alert after 10 hours, body temperature was returned to normal after 22 hours, and the laboratory tests were eventually returned to normal within 6 days. She was discharged from the hospital without any complication. We postulate that high dose PG E2 resulted in high fever, coronary artery spasm, and convulsion

Ergonovine Echocardiography for the Diagnosis of Vasospastic Angina

No abstract available.

Assessment of cardiac sympathetic neuronal integrity using iodine-123 metaiodobenzylguanidine myocardial scintigraphy and its clinical efficacy as a new noninvasive screening test for the diagnosis of coronary artery spasm

BACKGROUND: It has been suggested that the sympathetic nervous system might play an important role in the development of coronary artery spasm. Recently, advances have made possible the imaging of the cardiac adrenergic nervous system with metaiodobenzylguanidine (MIBG) labeled with iodine-123. The purpose of this study was to assess the presence and location of abnormal sympathetic innervation by iodine-123-metaiodobenzylguanidine single-photon emission computed tomography (SPECT) and to evaluate the clinical efficacy of iodine-123-MIBG SPECT as a noninvasive screening test in patients with coronary artery spasm. METHOD: Coronary arteriography and provocative test with intravenous administration of ergonovine maleate were performed in 26 patients (21 men, 5 women, mean age 49.1+/-9.3, range: 26-59) who were suspected of having a coronary artery spasm. The subjects were divided into 2 groups ; Group 1 comparised of 18 patients subjects to the positive provocative test, Group 2 comparised of 8 patients subjects to the negative provocative test. Four healthy subjects served as control. All patients also underwent iodine-123-MIBG SPECT for the evaluation of cardiac sympathetic integrity. The SPECT findings were qualitatively evaluated by two experienced physicians who were blind to the clinical data. RESULTS: Abnormal sympathetic nervous innervation using iodine-123-MIBG SPECT was observed either as a reduced uptake or defect pattern in the perfused areas in 13 of the 18 vessels of ergonovine induced vasospasm. Normal sympathetic innervation as evidenced by normal iodine-123-MIBG uptake was noted in all of the 60 segments of normal vessel territories. Reduced uptake of iodine-123-MIBG was not detected in the perfused areas of five vasospasm-induced vessels (perfusion territory of LAD in 2 and the RCA in 3 patients). The sensitivity and specificity of iodine-123-MIBG for detection coronary artery spasm were 72.2% (95% confidence interval [CI] 55% to 89%) and 100%, respectively. The positive predictive value and negative predictive value were 100% and 92.3% (95% CI 91% to 93%), respectively. CONCLUSION: Iodine-123-MIBG SPECT is a feasible method to noninvasively evaluate and localize the territories of coronary arteries with spasms. Invasive diagnostic coronary arteriography with ergonovine provocation test may be unnecessary for the diagnosis of coronary artery spasm in patients with typical resting pain, negative exercise test or normal thallium perfusion scan, but abnormal iodine-123-MIBG SPECT.

Increased basal tone and hyperresponsiveness to acetylcholine and ergonovine in spasm related coronary arteries in patients with variant angina: basal coronary artery tone in patients with variant angina

In patients with variant angina, previous data have been inconclusive as to whether basal coronary artery tone is elevated at the spastic and non-spastic sites. Thus, the purpose of this study was to assess the basa coronary artery tone and the responsiveness to acetylcholine (Ach) and ergonovine (Erg) in patients with variant angina. We compared the basal coronary artery tone and the constrictive responses to Ach and Erg between 31 patients (Group 1) with variant angina in whom spasm was provoked by the low doses of Ach (intracoronary 20 micrograms) or Erg(intravenous 50 micrograms) and 35 patients (Group 2) provoked by higher doses of Ach (intracoronary 100 micrograms) or Erg (intravenous cumulative dose of 350 micrograms), and 26 control subjects. Patients with variant angina in whom spasm was provoked by low doses of Ach or Erg, had a higher incidence of mixed disease, multi-vessel spasm and higher disease activity. The basal coronary artery tone at the spastic and nonspastic sites of spasm related artery was significantly more elevated in Group 1 than that in Group 2 (44+/- 17 vs 14 +/- 11% and 26 +/- 14 vs 16 +/- 10% respectively, P< 0.05), but not in the nonspasm related artery, The magnitudes of vasoconstrictive responses to Ach and Erg at the nonspastic sites were also greater in Group 1 than those in Group 2 and the control groups (Ach; 40 +/- 20 vs 26+/- 11, 27 +/- 12%: Erg; 37 +/- 18 vs 12 +/- 8, 13 +/- 10% respectively, P< 0.05). However, the basal coronary artery tone was not elevated at the spastic and nonspastic sites in Group 2 compared to the in control subjects. These findings suggest that the basal coronary artery tone is increased in patients with variant angina with higher disease activity at the spastic sites and nonspastic sites of the spasm-related artery, and this may be related to the occurrence of coronary artery spasm.