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1.
A A Pract ; 18(5): e01786, 2024 May 01.
Article in English | MEDLINE | ID: mdl-38708942

ABSTRACT

We report a case of a 62-year-old woman with a decade-long history of atypical chest pain resulting in a largely negative cardiac workup, who developed significant angiographically demonstrated coronary vasospasm thought to be due to a small dose of intravenous ketamine. In patients with a history of atypical chest pain despite a reassuring cardiac evaluation, providers should carefully consider medications that may precipitate coronary vasospasm and be prepared to treat it accordingly.


Subject(s)
Coronary Vasospasm , Ketamine , Humans , Coronary Vasospasm/chemically induced , Ketamine/adverse effects , Ketamine/administration & dosage , Female , Middle Aged , Chest Pain/chemically induced , Coronary Angiography
2.
JACC Cardiovasc Interv ; 17(9): 1091-1102, 2024 May 13.
Article in English | MEDLINE | ID: mdl-38749588

ABSTRACT

BACKGROUND: Invasive CFT is the gold standard for diagnosing coronary vasomotor dysfunction in patients with ANOCA. Most institutions recommend only testing the left coronary circulation. Therefore, it is unknown whether testing multiple coronary territories would increase diagnostic yield. OBJECTIVES: The aim of this study was to evaluate the diagnostic yield of multivessel, compared with single-vessel, invasive coronary function testing (CFT) in patients with angina and nonobstructive coronary arteries (ANOCA). METHODS: Multivessel CFT was systematically performed in patients with suspected ANOCA. Vasoreactivity testing was performed using acetylcholine provocation in the left (20 to 200 µg) and right (20 to 80µg) coronary arteries. A pressure-temperature sensor guidewire was used for coronary physiology assessment in all three epicardial vessels. RESULTS: This multicenter study included a total of 228 vessels from 80 patients (57.8 ± 11.8 years of age, 60% women). Compared with single-vessel CFT, multivessel testing resulted in more patients diagnosed with coronary vasomotor dysfunction (86.3% vs 68.8%; P = 0.0005), coronary artery spasm (60.0% vs 47.5%; P = 0.004), and CMD (62.5% vs 36.3%; P < 0.001). Coronary artery spasm (n = 48) predominated in the left coronary system (n = 38), though isolated right coronary spasm was noted in 20.8% (n = 10). Coronary microvascular dysfunction (CMD), defined by abnormal index of microcirculatory resistance and/or coronary flow reserve, was present 62.5% of the cohort (n = 50). Among the cohort with CMD, 27 patients (33.8%) had 1-vessel CMD, 15 patients (18.8%) had 2-vessel CMD, and 8 patients (10%) had 3-vessel CMD. CMD was observed at a similar rate in the territories supplied by all 3 major coronary vessels (left anterior descending coronary artery = 36.3%, left circumflex coronary artery = 33.8%, right coronary artery = 31.3%; P = 0.486). CONCLUSIONS: Multivessel CFT resulted in an increased diagnostic yield in patients with ANOCA compared with single-vessel testing. The results of this study suggest that multivessel CFT has a role in the management of patients with ANOCA.


Subject(s)
Acetylcholine , Angina Pectoris , Coronary Artery Disease , Coronary Circulation , Coronary Vasospasm , Coronary Vessels , Predictive Value of Tests , Vasodilator Agents , Humans , Female , Male , Middle Aged , Aged , Coronary Vessels/physiopathology , Coronary Vessels/diagnostic imaging , Vasodilator Agents/administration & dosage , Coronary Vasospasm/physiopathology , Coronary Vasospasm/diagnosis , Acetylcholine/administration & dosage , Angina Pectoris/physiopathology , Angina Pectoris/diagnosis , Angina Pectoris/etiology , Coronary Artery Disease/physiopathology , Coronary Artery Disease/diagnosis , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/therapy , Cardiac Catheterization , Coronary Angiography , Reproducibility of Results , Vasodilation , Vasoconstriction
3.
Int Heart J ; 65(2): 349-353, 2024.
Article in English | MEDLINE | ID: mdl-38556342

ABSTRACT

Tyrosine kinase inhibitors (TKIs) are essential drugs for chronic myeloid leukemia and Philadelphia chromosome-positive acute lymphoblastic leukemia. Cardiovascular or arteriothrombotic adverse events have been reported in patients treated with TKIs. We report 3 cases of Ponatinib-related vasospastic angina, in which prophylactic administration of nitrates or calcium channel blockers was effective.


Subject(s)
Coronary Vasospasm , Leukemia, Myelogenous, Chronic, BCR-ABL Positive , Precursor Cell Lymphoblastic Leukemia-Lymphoma , Pyridazines , Humans , Coronary Vasospasm/chemically induced , Coronary Vasospasm/drug therapy , Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy , Leukemia, Myelogenous, Chronic, BCR-ABL Positive/chemically induced , Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy , Precursor Cell Lymphoblastic Leukemia-Lymphoma/chemically induced , Imidazoles/pharmacology , Pyridazines/adverse effects
4.
Int Heart J ; 65(2): 354-358, 2024.
Article in English | MEDLINE | ID: mdl-38556343

ABSTRACT

Although long-QT syndrome (LQTS) with a normal range QT interval at rest leads to fatal ventricular arrhythmias, it is difficult to diagnose. In this article, we present a rare case of a patient who suffered a cardiac arrest and was recently diagnosed with LQTS and coronary vasospasm. A 62-year-old man with no syncopal episodes had a cardiopulmonary arrest while running. During coronary angiography, vasospasm was induced and we prescribed coronary vasodilators, including calcium channel blockers. An exercise stress test was performed to evaluate the effect of medications and accidentally unveiled exercise-induced QT prolongation. He was diagnosed with LQTS based on diagnostic criteria. Pharmacotherapy and an implantable cardioverter defibrillator were used for his medical management. It is extremely rare for LQTS and coronary vasospasm to coexist. In cases of exercise-induced arrhythmic events, the exercise stress test might be helpful to diagnose underlying disease.


Subject(s)
Coronary Vasospasm , Heart Arrest , Long QT Syndrome , Male , Humans , Middle Aged , Ventricular Fibrillation/complications , Ventricular Fibrillation/diagnosis , Coronary Vasospasm/complications , Coronary Vasospasm/diagnosis , Electrocardiography , Long QT Syndrome/complications , Long QT Syndrome/diagnosis , Arrhythmias, Cardiac/complications , Heart Arrest/complications
6.
Inn Med (Heidelb) ; 65(5): 495-502, 2024 May.
Article in German | MEDLINE | ID: mdl-38517528

ABSTRACT

BACKGROUND: Clinical management of patients with angina and no obstructive coronary artery disease (ANOCA) is still challenging. This scenario affects up to 50% of patients undergoing diagnostic coronary angiography due to suspected coronary artery disease. Many patients report a long and debilitating history before adequate diagnostics and management are initiated. OBJECTIVES: This article describes the current recommendations for diagnostic assessments and treatment in patients with ANOCA. Focus is placed on invasive diagnostics in the catheter laboratory, pharmacological/interventional treatment as well as the patient journey. RESULTS: In patients with ANOCA, the current European Society of Cardiology (ESC) guidelines suggest that invasive assessments using acetylcholine and adenosine for the diagnosis of an underlying coronary vasomotor disorder should be considered. Acetylcholine is used to diagnose coronary spasm, whereas adenosine is used in conjunction with a wire-based assessment for the measurement of coronary flow reserve and microvascular resistance. The invasive assessments allow the determination of what are referred to as endotypes (coronary spasm, impaired coronary flow reserve, enhanced microvascular resistance or a combination thereof). Establishing a diagnosis is helpful to: (a) initiate targeted treatment to improve quality of life, (b) reassure the patient that a cardiac cause is found and (c) to assess individual prognosis. CONCLUSIONS: Currently, patients with ANOCA are often not adequately managed. Referral to specialised centres is recommended to prevent long and debilitating patient histories until expertise in diagnosis and treatment becomes more widespread.


Subject(s)
Angina Pectoris , Coronary Angiography , Humans , Coronary Angiography/methods , Angina Pectoris/therapy , Angina Pectoris/diagnostic imaging , Angina Pectoris/diagnosis , Coronary Vasospasm/diagnostic imaging , Coronary Vasospasm/diagnosis , Coronary Vasospasm/therapy , Acetylcholine , Adenosine/administration & dosage
7.
Atherosclerosis ; 391: 117503, 2024 Apr.
Article in English | MEDLINE | ID: mdl-38447435

ABSTRACT

BACKGROUND AND AIMS: Acetylcholine (ACh) provocation testing can detect vasomotor disorders in patients with ischemia and non-obstructed coronary arteries (INOCA) or myocardial infarction and non-obstructed coronary arteries (MINOCA). We aimed to derive and validate a simple risk score to predict a positive ACh test response. METHODS: We prospectively enrolled consecutive INOCA and MINOCA patients undergoing ACh provocation testing. Patients were split in two cohorts (derivation and validation) according to time of enrolment. The score was derived in 386 patients (derivation cohort) and then validated in 165 patients (validation cohort). RESULTS: 551 patients were enrolled, 371 (67.3%) INOCA and 180 (32.7%) MINOCA. ACh test was positive in 288 (52.3%) patients. MINOCA, myocardial bridge (MB), C-reactive protein (CRP) and dyslipidaemia were independent predictors of a positive ACh test in the derivation cohort. The ABCD (Acute presentation, Bridge, CRP, Dyslipidaemia) score was derived: 2 points were assigned to MINOCA, 3 to MB, 1 to elevated CRP and 1 to dyslipidaemia. The ABCD score accurately identified patients with a positive ACh test response with an AUC of 0.703 (CI 95% 0.652-0.754,p < 0.001) in the derivation cohort, and 0.705 (CI 95% 0.626-0.784, p < 0.001) in the validation cohort. In the whole population, an ABCD score ≥4 portended 94.3% risk of a positive ACh test and all patients with an ABCD score ≥6 presented a positive test. CONCLUSIONS: The ABCD score could avoid the need of ACh provocation testing in patients with a high score, reducing procedural risks, time, and costs, and allowing the implementation of a tailored treatment strategy. These results are hypothesis generating and further research involving larger cohorts and multicentre trials is needed to validate and refine the ABCD score.


Subject(s)
Coronary Artery Disease , Coronary Vasospasm , Dyslipidemias , Myocardial Infarction , Humans , Acetylcholine , Coronary Vessels , MINOCA , Coronary Angiography/methods , C-Reactive Protein , Coronary Artery Disease/diagnosis
8.
Int J Mol Sci ; 25(5)2024 Mar 03.
Article in English | MEDLINE | ID: mdl-38474189

ABSTRACT

Coronary artery spasm (CAS) plays an important role in the pathogeneses of various ischemic heart diseases and has gradually become a common cause of life-threatening arrhythmia. The specific molecular mechanism of CAS has not been fully elucidated, nor are there any specific diagnostic markers for the condition. Therefore, this study aimed to examine the specific molecular mechanism underlying CAS, and screen for potential diagnostic markers. To this end, we successfully constructed a rat CAS model and achieved in vitro culture of a human coronary-artery smooth-muscle cell (hCASMC) contraction model. Possible molecular mechanisms by which protein kinase C (PKC) regulated CAS through the C kinase-potentiated protein phosphatase 1 inhibitor of 17 kDa (CPI-17)/myosin II regulatory light chain (MLC2) pathway were studied in vivo and in vitro to screen for potential molecular markers of CAS. We performed hematoxylin and eosin staining, myocardial zymogram, and transmission electron microscopy to determine myocardial and coronary artery injury in CAS rats. Then, using immunohistochemical staining, immunofluorescence staining, and Western blotting, we further demonstrated a potential molecular mechanism by which PKC regulated CAS via the CPI-17/MLC2 pathway. The results showed that membrane translocation of PKCα occurred in the coronary arteries of CAS rats. CPI-17/MLC2 signaling was observably activated in coronary arteries undergoing CAS. In addition, in vitro treatment of hCASMCs with angiotensin II (Ang II) increased PKCα membrane translocation while consistently activating CPI-17/MLC2 signaling. Conversely, GF-109203X and calphostin C, specific inhibitors of PKC, inactivated CPI-17/MLC2 signaling. We also collected the coronary artery tissues from deceased subjects suspected to have died of CAS and measured their levels of phosphorylated CPI-17 (p-CPI-17) and MLC2 (p-MLC2). Immunohistochemical staining was positive for p-CPI-17 and p-MLC2 in the tissues of these subjects. These findings suggest that PKCα induced CAS through the CPI-17/MLC2 pathway; therefore, p-CPI-17 and p-MLC2 could be used as potential markers for CAS. Our data provide novel evidence that therapeutic strategies against PKC or CPI-17/MLC2 signaling might be promising in the treatment of CAS.


Subject(s)
Coronary Vasospasm , Animals , Humans , Rats , Biomarkers/metabolism , Death, Sudden, Cardiac , Phosphoproteins/metabolism , Phosphorylation , Protein Kinase C/metabolism , Protein Kinase C-alpha/metabolism
9.
J Med Case Rep ; 18(1): 153, 2024 Mar 12.
Article in English | MEDLINE | ID: mdl-38468268

ABSTRACT

BACKGROUND: Ischemia with non-obstructive coronary artery disease is a prevalent form of ischemic heart disease. The majority of ischemia with non-obstructive coronary artery disease cases are attributed to underlying factors such as coronary microvascular dysfunction (CMD) and/or coronary artery spasm. Ischemia with non-obstructive coronary artery disease can present with various clinical manifestations. Recurrent syncope is an atypical complaint in patients with ischemia with non-obstructive coronary artery disease. CASE PRESENTATION: This case report describes the presentation of a 58-year-old Chinese male patient who experienced repeated episodes of syncope. The syncope was found to be caused by concomitant coronary artery spasm and presumptive coronary microvascular dysfunctionc suggested by "slow flow" on coronary angiography. The patient was prescribed diltiazem sustained-release capsules, nicorandil, and atorvastatin. During the three-month follow-up conducted on our outpatient basis, the patient did not experience a recurrence of syncope. CONCLUSION: This study highlights the importance of considering ischemia with non-obstructive coronary artery disease as a potential cause of syncope in the differential diagnosis. It emphasizes the need for early diagnosis of ischemia with non-obstructive coronary artery disease to facilitate more effective management strategies.


Subject(s)
Coronary Artery Disease , Coronary Vasospasm , Myocardial Ischemia , Male , Humans , Middle Aged , Coronary Artery Disease/complications , Coronary Artery Disease/diagnostic imaging , Coronary Vasospasm/diagnosis , Coronary Vasospasm/diagnostic imaging , Myocardial Ischemia/complications , Coronary Angiography , Syncope/etiology , Ischemia , Coronary Vessels
10.
Am J Cardiol ; 219: 71-76, 2024 May 15.
Article in English | MEDLINE | ID: mdl-38522651

ABSTRACT

The diagnosis of vasospastic angina (VSA) according to Japanese guidelines involves an initial intracoronary acetylcholine (ACh) provocation test in the left coronary artery (LCA) followed by testing in the right coronary artery (RCA). However, global variations in test protocols often lead to the omission of ACh provocation in the RCA, potentially resulting in the underdiagnosis of VSA. This study assessed the validity of the LCA-only ACh provocation approach for the VSA diagnosis and whether vasoreactivity in the LCA aids in determining further provocation in the RCA. A total of 273 patients who underwent sequential intracoronary ACh provocation testing in the LCA and RCA were included. Patients with a positive ACh provocation test in the LCA were excluded. Relations between vasoreactivity in the LCA and ACh test outcomes (positivity and adverse events) in the RCA were evaluated. In patients with negative ACh test results in the LCA, subsequent ACh testing was positive in the RCA in 23 of 273 (8.4%) patients. In patients with minimal LCA vasoconstriction (<25%), only 3.0% had a positive ACh test in the RCA, whereas the ACh test in the RCA was positive in 13.5% of those with LCA constriction of 25% to 90% (p = 0.002). No major adverse events occurred during ACh testing in the RCA. In conclusion, for the VSA diagnosis, the omission of ACh provocation in the RCA may be clinically acceptable, particularly when vasoconstriction induced by ACh injection was minimal in the LCA. Further studies are needed to define ACh provocation protocols worldwide.


Subject(s)
Acetylcholine , Coronary Vasospasm , Coronary Vessels , Vasoconstriction , Humans , Acetylcholine/administration & dosage , Acetylcholine/pharmacology , Female , Male , Coronary Vasospasm/diagnosis , Coronary Vasospasm/physiopathology , Coronary Vasospasm/chemically induced , Coronary Vessels/physiopathology , Coronary Vessels/drug effects , Aged , Middle Aged , Vasoconstriction/physiology , Vasoconstriction/drug effects , Coronary Angiography , Vasodilator Agents/administration & dosage , Retrospective Studies , Angina Pectoris/physiopathology , Angina Pectoris/diagnosis
11.
Heart Vessels ; 39(5): 382-391, 2024 May.
Article in English | MEDLINE | ID: mdl-38324195

ABSTRACT

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.


Subject(s)
Cardiovascular Agents , Coronary Artery Disease , Coronary Stenosis , Coronary Vasospasm , Diabetes Mellitus , Humans , Prognosis , Coronary Artery Disease/complications , Angina Pectoris/diagnosis , Angina Pectoris/epidemiology , Angina Pectoris/etiology , Coronary Vasospasm/complications , Coronary Vasospasm/diagnosis , Coronary Vasospasm/epidemiology , Coronary Stenosis/diagnosis , Coronary Stenosis/diagnostic imaging , Chest Pain/diagnosis , Chest Pain/epidemiology , Chest Pain/etiology , Diabetes Mellitus/epidemiology , Risk Factors , Coronary Angiography/adverse effects
12.
Coron Artery Dis ; 35(4): 309-313, 2024 Jun 01.
Article in English | MEDLINE | ID: mdl-38411142

ABSTRACT

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.


Subject(s)
Coronary Angiography , Coronary Vasospasm , Genetic Predisposition to Disease , Interleukin-6 , North African People , Smoking , Humans , Egypt/epidemiology , Male , Female , Middle Aged , Interleukin-6/genetics , Coronary Vasospasm/genetics , Coronary Vasospasm/diagnosis , Coronary Vasospasm/epidemiology , Case-Control Studies , Risk Factors , Smoking/adverse effects , Smoking/epidemiology , Aged , Cardiac Catheterization , Gene Frequency , Phenotype , Cardiac Catheters , Genetic Association Studies , Polymorphism, Single Nucleotide , Polymorphism, Genetic
14.
Eur J Clin Invest ; 54(6): e14178, 2024 Jun.
Article in English | MEDLINE | ID: mdl-38348627

ABSTRACT

BACKGROUND: Given the limited access to invasive vasospastic reactivity testing in Western Countries, there is a need to further develop alternative non-invasive diagnostic methods for vasospastic angina (VSA). Hyperventilation testing (HVT) is defined as a class IIa recommendation to diagnose VSA by the Japanese Society of Cardiology. METHODS: In this systematic review and meta-analysis reported according to the PRISMA statement, we review the mechanisms, methods, modalities and diagnostic accuracy of non-invasive HVT for the diagnostic of VSA. RESULTS: A total of 106 articles published between 1980 and 2022 about VSA and HVT were included in the systematic review, among which 16 were included in the meta-analysis for diagnostic accuracy. Twelve electrocardiogram-HVT studies including 804 patients showed a pooled sensitivity of 54% (95% confidence intervals [CI]; 30%-76%) and a pooled specificity of 99% (95% CI; 88%-100%). Four transthoracic echocardiography-HVT studies including 197 patients revealed a pooled sensitivity of 90% (95% CI; 82%-94%) and a pooled specificity of 98% (95% CI; 86%-100%). Six myocardial perfusion imaging-HVT studies including 112 patients yielded a pooled sensitivity of 95% (95% CI; 63%-100%) and a pooled specificity of 78% (95% CI; 19%-98%). Non-invasive HVT resulted in a low rate of adverse events, ventricular arrhythmias being the most frequently reported, and were resolved with the administration of nitroglycerin. CONCLUSIONS: Non-invasive HVT offers a safe alternative with high diagnostic accuracy to diagnose VSA in patients with otherwise undiagnosed causes of chest pain.


Subject(s)
Coronary Vasospasm , Echocardiography , Electrocardiography , Hyperventilation , Humans , Hyperventilation/diagnosis , Hyperventilation/physiopathology , Coronary Vasospasm/diagnosis , Coronary Vasospasm/physiopathology , Angina Pectoris/diagnosis , Angina Pectoris/physiopathology , Sensitivity and Specificity , Myocardial Perfusion Imaging
15.
Am J Cardiol ; 217: 49-58, 2024 Apr 15.
Article in English | MEDLINE | ID: mdl-38417650

ABSTRACT

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.


Subject(s)
Acetylcholine , Coronary Vasospasm , Humans , Coronary Angiography , Coronary Vasospasm/diagnosis , Coronary Vasospasm/epidemiology , Vasoconstriction , Angina Pectoris , Coronary Vessels/diagnostic imaging
16.
J Invasive Cardiol ; 36(5)2024 May.
Article in English | MEDLINE | ID: mdl-38422533

ABSTRACT

A 60-year-old male presented to the emergency department of our hospital with persistent dull pain in the lower and middle sternum with generalized sweating after a heated argument with another person, and his symptoms did not resolve after 3 hours of onset.


Subject(s)
Coronary Angiography , Coronary Vasospasm , Electrocardiography , Humans , Male , Middle Aged , Coronary Vasospasm/diagnosis , Coronary Vasospasm/physiopathology , Coronary Angiography/methods , Coronary Vessels/diagnostic imaging
17.
Ther Adv Cardiovasc Dis ; 18: 17539447241230400, 2024.
Article in English | MEDLINE | ID: mdl-38343041

ABSTRACT

Vasospastic angina (VSA) refers to chest pain experienced as a consequence of myocardial ischaemia caused by epicardial coronary spasm, a sudden narrowing of the vessels responsible for an inadequate supply of blood and oxygen. Coronary artery spasm is a heterogeneous phenomenon that can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction (MI). VSA was originally described as Prinzmetal angina or variant angina, classically presenting at rest, unlike most cases of angina (though in some patients, vasospasm may be triggered by exertion, emotional, mental or physical stress), and associated with transient electrocardiographic changes (transient ST-segment elevation, depression and/or T-wave changes). Ischaemia with non-obstructive coronary arteries (INOCA) is not a benign condition, as patients are at elevated risk of cardiovascular events including acute coronary syndrome, hospitalization due to heart failure, stroke and repeat cardiovascular procedures. INOCA patients also experience impaired quality of life and associated increased healthcare costs. VSA, an endotype of INOCA, is associated with major adverse events, including sudden cardiac death, acute MI and syncope, necessitating the study of the most effective treatment options currently available. The present literature review aims to summarize current data relating to the diagnosis and management of VSA and provide details on the sequence that treatment should follow.


Diagnosis and treatment of epicardial coronary artery spasmVasospastic angina (VSA) refers to chest pain experienced as a consequence of a sudden narrowing of the epicardial coronary arteries. VSA can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction. Reduced blood and oxygen supply in patients with non-obstructive coronary arteries is not a benign condition, as patients are at elevated risk of adverse cardiovascular events. These patients also experience impaired quality of life and associated increased healthcare costs. This review aims to summarise current data relating to the diagnosis of VSA and provides details on treatment strategies.


Subject(s)
Angina Pectoris, Variant , Coronary Artery Disease , Coronary Vasospasm , Myocardial Infarction , Humans , Angina Pectoris, Variant/diagnosis , Angina Pectoris, Variant/therapy , Angina Pectoris, Variant/complications , Coronary Vasospasm/diagnosis , Coronary Vasospasm/therapy , Coronary Vasospasm/complications , Quality of Life , Coronary Angiography/adverse effects , Chest Pain/complications , Spasm/complications
18.
Ther Adv Cardiovasc Dis ; 18: 17539447241233168, 2024.
Article in English | MEDLINE | ID: mdl-38396350

ABSTRACT

BACKGROUND: Although guidelines recommend intracoronary acetylcholine (ACh) and ergonovine (ER) provocation testing for diagnosis of vasospastic angina, the feasibility and safety of sequential (combined) use of both pharmacological agents during the same catheterization session remain unclear. OBJECTIVES: In this study, we investigated the feasibility and safety of sequential intracoronary ACh and ER administration for coronary spasm provocation testing. METHODS: The study included 235 patients who showed positive results on ACh and ER provocation testing. Initial intracoronary ACh administration was followed by ER administration for left coronary artery (LCA) spasm provocation testing. Subsequently, the right coronary artery (RCA) was subjected to sequential ACh and ER administration for provocation testing. The primary outcome of the study was the safety of sequential intracoronary ACh and ER provocation testing, which was assessed based on a composite of all-cause death, sustained ventricular tachycardia and fibrillation, and cardiogenic shock. RESULTS: Even in patients with negative results on sequential intracoronary ACh and ER provocation testing in the LCA and only ACh administration into the RCA, additional administration of ER into the RCA showed a positive provocation test result in 33 of 235 (14.0%) patients; three (1.3%) patients developed adverse effects (cardiogenic shock occurred in all cases) during LCA provocation testing. We observed no deaths attributable to spasm provocation testing. CONCLUSION: Sequential administration of intracoronary ACh and ER was associated with a relatively low major complication rate and may be safe and potentially useful for diagnosis of vasospastic angina.


Safety and potential usefulness of novel coronary spasm provocation testing protocolCoronary spasm represents a subtype of ischemic heart disease, potentially leading to heart attack. Although guidelines recommend intracoronary administration of different pharmacological agents, acetylcholine (ACh) and ergonovine (ER), for coronary spasm provocation testing, the feasibility and safety of sequential (combined) use of both drugs are unclear. In the present study, we showed that sequential administration of intracoronary ACh and ER was associated with a relatively low major complication rate and may be safe and potentially useful for diagnosis of coronary vasospasm.


Subject(s)
Angina Pectoris, Variant , Coronary Vasospasm , Humans , Acetylcholine/adverse effects , Ergonovine/adverse effects , Coronary Vasospasm/chemically induced , Coronary Vasospasm/diagnosis , Shock, Cardiogenic/chemically induced , Coronary Angiography , Coronary Vessels , Angina Pectoris, Variant/chemically induced , Spasm/chemically induced
19.
EuroIntervention ; 20(2): e123-e134, 2024 Jan 15.
Article in English | MEDLINE | ID: mdl-38224252

ABSTRACT

Increasing evidence has shown that coronary spasm and vasomotor dysfunction may be the underlying cause in more than half of myocardial infarctions with non-obstructive coronary arteries (MINOCA) as well as an important cause of chronic chest pain in the outpatient setting. We review the contemporary understanding of coronary spasm and related vasomotor dysfunction of the coronary arteries, the pathophysiology and prognosis, and current and emerging approaches to diagnosis and evidence-based treatment.


Subject(s)
Coronary Vasospasm , MINOCA , Humans , Coronary Vasospasm/complications , Coronary Vasospasm/diagnostic imaging , Chest Pain , Coronary Vessels/diagnostic imaging , Coronary Vessels/surgery , Spasm
20.
Medicine (Baltimore) ; 103(2): e36889, 2024 Jan 12.
Article in English | MEDLINE | ID: mdl-38215100

ABSTRACT

RATIONALE: Diffuse multivessel coronary artery spasm (DMV-CAS) was defined as a severe and reversible diffuse spasm occurring in more than 2 major coronary arteries, which is rare in clinical practice. Due to a wide lesion scope, DMV-CAS often occurs in the form of complications. It is not easy to be clinically diagnosed because it is too brief to be caught. Here, we report a rare case of spontaneous subtotal occlusion of 3 major coronary arteries induced by Vasalva action, which was confirmed in real-time by CAG. PATIENT CONCERNS: A 68-year-old man had sudden chest pain after forced defecation during hospitalization. The electrocardiogram showed transient ST segment elevation of the inferior wall lead, inversion of the anterior wall, and lateral wall leads T waves. Emergency CAG revealed elongated vessel beds in 3 coronary arteries and multiple diffuse stenosis, but none of the coronary arteries were completely occlusive. DIAGNOSES: Diagnoses of DMV-CAS were made based on CAG findings and postmedication response. INTERVENTIONS: Nitroglycerin was administered in the coronary arteries. The anti-vasospasm, antiplatelet aggregation and lipid-regulating drugs were administered orally. OUTCOMES: The patient was discharged on the 7th day with complete resolution of symptoms and normalization of the electrocardiography findings. No ischemic events occurred during a follow-up for 5 months. LESSONS: This case highlights the identification of multivessel diffuse coronary spasm and acute myocardial infarction, and the prevention of CAS triggers, which requires the attention of clinicians.


Subject(s)
Coronary Vasospasm , Myocardial Infarction , Male , Humans , Aged , Coronary Vessels/diagnostic imaging , Coronary Angiography/adverse effects , Coronary Vasospasm/complications , Coronary Vasospasm/diagnosis , Myocardial Infarction/complications , Nitroglycerin/therapeutic use , Electrocardiography , Arrhythmias, Cardiac/drug therapy
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