Provocative testing for coronary reactivity and spasm

Melody Zaya, Puja K Mehta, C Noel Bairey Merz, Melody Zaya, Puja K Mehta, C Noel Bairey Merz

Abstract

Coronary spasm is an important and often overlooked etiology of chest pain. Although coronary spasm, or Prinzmetal's angina, has been thought of as benign, contemporary studies have shown serious associated adverse outcomes, including acute coronary syndrome, arrhythmia, and death. Definitive diagnosis of coronary spasm can at times be difficult, given the transience of symptoms. Numerous agents have been historically described for provocative testing. We provide a review of published data for the role of provocation testing in the diagnosis of coronary spasm.

Keywords: ACH; CFR; CS; ER; IC; IV; MI; Prinzmetal's angina; SCA; acetylcholine; coronary flow reserve; coronary spasm; ergonovine; intracoronary; intravenous; myocardial infarction; provocation testing; sudden cardiac arrest.

Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1. Coronary spasm
Figure 1. Coronary spasm
Angiogram before (a) and after (b) administration of 200 micrograms IV ergonovine showing focal spasm of the left anterior descending artery (courtesy of Adlam, et al (59), reprint permission requested). Angiogram before (c) and after (d) intracoronary infusion of acetylcholine at a concentration of 0.182 micrograms/milliliter (2 milliliters over 3 minutes) showing diffuse spasm of the left anterior descending artery.
Figure 2. Variant angina algorithm
Figure 2. Variant angina algorithm
Suspicion is based on clinical factors: Spontaneous episodes of angina occurring at rest and between night and early morning hours, marked diurnal variation in exercise tolerance (reduced during early morning hours), quick relief of angina with nitrates, suppression of attacks with calcium channel blockers (CCBs), smoking, Asian descent. CAD=coronary artery disease, ER=Ergonovine, ACH=Acetylcholine, EKG= electrocardiogram.

References

    1. Yasue H, Takizawa A, Nagao M, et al. Long-term prognosis for patients with variant angina and influential factors. Circulation. 1988;78:1–9.
    1. Wang CH, Kuo LT, Hung MJ, Cherng WJ. Coronary vasospasm as a possible cause of elevated cardiac troponin I in patients with acute coronary syndrome and insignificant coronary artery disease. Am Heart J. 2002;144:275–81.
    1. MacAlpin RN. Cardiac arrest and sudden unexpected death in variant angina: complications of coronary spasm that can occur in the absence of severe organic coronary stenosis. Am Heart J. 1993;125:1011–7.
    1. Togashi I, Sato T, Soejima K, et al. Sudden cardiac arrest and syncope triggered by coronary spasm. Int J Cardiol. 2013;163:56–60.
    1. Takatsu F, Watarai M. Mild stenosis makes prognosis of vasospastic angina worse. Coron Artery Dis. 2011;22:1–5.
    1. Hackett D, Larkin S, Chierchia S, Davies G, Kaski JC, Maseri A. Induction of coronary artery spasm by a direct local action of ergonovine. Circulation. 1987;75:577–82.
    1. Clarke JG, Davies GJ, Kerwin R, et al. Coronary artery infusion of neuropeptide Y in patients with angina pectoris. Lancet. 1987;1:1057–9.
    1. Okumura K, Yasue H, Horio Y, et al. Multivessel coronary spasm in patients with variant angina: a study with intracoronary injection of acetylcholine. Circulation. 1988;77:535–42.
    1. Crea F, Chierchia S, Kaski JC, et al. Provocation of coronary spasm by dopamine in patients with active variant angina pectoris. Circulation. 1986;74:262–9.
    1. Akasaka T, Yoshida K, Hozumi T, et al. Comparison of coronary flow reserve between focal and diffuse vasoconstriction induced by ergonovine in patients with vasospastic angina. Am J Cardiol. 1997;80:705–10.
    1. Bertrand ME, LaBlanche JM, Tilmant PY, et al. Frequency of provoked coronary arterial spasm in 1089 consecutive patients undergoing coronary arteriography. Circulation. 1982;65:1299–306.
    1. Harding MB, Leithe ME, Mark DB, et al. Ergonovine maleate testing during cardiac catheterization: a 10-year perspective in 3,447 patients without significant coronary artery disease or Prinzmetal’s variant angina. J Am Coll Cardiol. 1992;20:107–11.
    1. Sueda S, Kohno H, Fukuda H, et al. Induction of coronary artery spasm by two pharmacological agents: comparison between intracoronary injection of acetylcholine and ergonovine. Coron Artery Dis. 2003;14:451–7.
    1. Sueda S, Kohno H, Fukuda H, et al. Clinical impact of selective spasm provocation tests: comparisons between acetylcholine and ergonovine in 1508 examinations. Coron Artery Dis. 2004;15:491–7.
    1. Sueda S, Ochi T, Yano K, et al. New combined spasm provocation test in patients with rest angina: intracoronary injection of acetylcholine after intracoronary administration of ergonovine. Jpn Circ J. 2000;64:559–65.
    1. Sueda S, Ochi N, Kawada H, Uraoka T. Usefulness of intracoronary injection of acetylcholine and ergonovine in patients with variant angina. J Cardiol. 1998;31:145–50.
    1. Waters DD, Szlachcic J, Bonan R, Miller DD, Dauwe F, Theroux P. Comparative sensitivity of exercise, cold pressor and ergonovine testing in provoking attacks of variant angina in patients with active disease. Circulation. 1983;67:310–5.
    1. Takagi Y, Yasuda S, Takahashi J, et al. Clinical implications of provocation tests for coronary artery spasm: safety, arrhythmic complications, and prognostic impact: multicentre registry study of the Japanese Coronary Spasm Association. Eur Heart J. 2013;34:258–67.
    1. Song JK, Park SW, Kang DH, et al. Safety and clinical impact of ergonovine stress echocardiography for diagnosis of coronary vasospasm. J Am Coll Cardiol. 2000;35:1850–6.
    1. Song JK, Lee SJ, Kang DH, et al. Ergonovine echocardiography as a screening test for diagnosis of vasospastic angina before coronary angiography. J Am Coll Cardiol. 1996;27:1156–61.
    1. Yasue H, Horio Y, Nakamura N, et al. Induction of coronary artery spasm by acetylcholine in patients with variant angina: possible role of the parasympathetic nervous system in the pathogenesis of coronary artery spasm. Circulation. 1986;74:955–63.
    1. Okumura K, Yasue H, Matsuyama K, Goto K, Miyagi H, Ogawa H. Sensitivity and specificity of intracoronary injection of acetylcholine for the induction of coronary artery spasm. J Am Coll Cardiol. 1988;12:883–8.
    1. Sueda S, Ochi N, Kawada H, et al. Frequency of provoked coronary vasospasm in patients undergoing coronary arteriography with spasm provocation test of acetylcholine. Am J Cardiol. 1999;83:1186–90.
    1. Suyama A, Kuriyama H. Mechanisms of the ergonovine-induced vasoconstriction in the rabbit main coronary artery. Naunyn Schmiedebergs Arch Pharmacol. 1984;326:357–63.
    1. Lacy CFAL, Goldman MP, Lance LL, editors. Drug Information Handbook. 17. Hudson: Lexi-Comp Inc; 2008.
    1. Furchgott RF, Zawadzki JV. The obligatory role of endothelial cells in the relaxation of arterial smooth muscle by acetylcholine. Nature. 1980;288:373–6.
    1. Eshaghpour E, Mattioli L, Williams ML, Moghadam AN. Acetylcholine in the treatment of idiopathic respiratory distress syndrome. J Pediatr. 1967;71:243–6.
    1. Sueda S, Saeki H, Otani T, et al. Major complications during spasm provocation tests with an intracoronary injection of acetylcholine. Am J Cardiol. 2000;85:391–4. A10.
    1. Kim YG, Kim HJ, Choi WS, et al. Does a negative ergonovine provocation test truly predict freedom from variant angina? Korean Circ J. 2013;43:199–203.
    1. Oliva PB, Potts DE, Pluss RG. Coronary arterial spasm in Prinzmetal angina. Documentation by coronary arteriography. N Engl J Med. 1973;288:745–51.
    1. Prinzmetal M, Kennamer R, Merliss R, Wada T, Bor N. Angina pectoris. I. A variant form of angina pectoris; preliminary report. Am J Med. 1959;27:375–88.
    1. Sun H, Mohri M, Shimokawa H, Usui M, Urakami L, Takeshita A. Coronary microvascular spasm causes myocardial ischemia in patients with vasospastic angina. J Am Coll Cardiol. 2002;39:847–51.
    1. Kaski JC, Maseri A, Vejar M, Crea F, Hackett D. Spontaneous coronary artery spasm in variant angina is caused by a local hyperreactivity to a generalized constrictor stimulus. J Am Coll Cardiol. 1989;14:1456–63.
    1. Amano M, Ito M, Kimura K, et al. Phosphorylation and activation of myosin by Rho-associated kinase (Rho-kinase) J Biol Chem. 1996;271:20246–9.
    1. Chataigneau T, Feletou M, Huang PL, Fishman MC, Duhault J, Vanhoutte PM. Acetylcholine-induced relaxation in blood vessels from endothelial nitric oxide synthase knockout mice. Br J Pharmacol. 1999;126:219–26.
    1. Popp R, Fleming I, Busse R. Pulsatile stretch in coronary arteries elicits release of endothelium-derived hyperpolarizing factor: a modulator of arterial compliance. Circ Res. 1998;82:696–703.
    1. Bossaller C, Habib GB, Yamamoto H, Williams C, Wells S, Henry PD. Impaired muscarinic endothelium-dependent relaxation and cyclic guanosine 5′-monophosphate formation in atherosclerotic human coronary artery and rabbit aorta. The Journal of clinical investigation. 1987;79:170–4.
    1. Yamagishi M, Miyatake K, Tamai J, Nakatani S, Koyama J, Nissen SE. Intravascular ultrasound detection of atherosclerosis at the site of focal vasospasm in angiographically normal or minimally narrowed coronary segments. J Am Coll Cardiol. 1994;23:352–7.
    1. Bertrand ME, Lablanche JM, Tilmant PY, Ducloux G, Warembourg H, Jr, Soots G. Complete denervation of the heart (autotransplantation) for treatment of severe, refractory coronary spasm. Am J Cardiol. 1981;47:1375–8.
    1. Sugiishi M, Takatsu F. Cigarette smoking is a major risk factor for coronary spasm. Circulation. 1993;87:76–9.
    1. Suzuki M, Nishizaki M, Arita M, Kakuta T, Numano F. Impaired glucose tolerance with late hypersecretion of insulin during oral glucose tolerance test in patients with vasospastic angina. J Am Coll Cardiol. 1996;27:1458–63.
    1. Beltrame JF, Sasayama S, Maseri A. Racial heterogeneity in coronary artery vasomotor reactivity: differences between Japanese and Caucasian patients. J Am Coll Cardiol. 1999;33:1442–52.
    1. Sueda S, Kohno H, Fukuda H, et al. Frequency of provoked coronary spasms in patients undergoing coronary arteriography using a spasm provocation test via intracoronary administration of ergonovine. Angiology. 2004;55:403–11.
    1. Murase Y, Yamada Y, Hirashiki A, et al. Genetic risk and gene-environment interaction in coronary artery spasm in Japanese men and women. Eur Heart J. 2004;25:970–7.
    1. Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2008): digest version. Circ J. 2010;74:1745–62.
    1. Krahn AD, Healey JS, Chauhan V, et al. Systematic assessment of patients with unexplained cardiac arrest: Cardiac Arrest Survivors With Preserved Ejection Fraction Registry (CASPER) Circulation. 2009;120:278–85.
    1. Igarashi Y, Tamura Y, Suzuki K, et al. High prevalence of coronary artery spasm in survivors of cardiac arrest with no apparent heart disease. Jpn Heart J. 1992;33:653–63.
    1. Chevalier P, Dacosta A, Defaye P, et al. Arrhythmic cardiac arrest due to isolated coronary artery spasm: long-term outcome of seven resuscitated patients. J Am Coll Cardiol. 1998;31:57–61.
    1. Scardi S, Pivotti F, Pandullo C, Ceschia G, Salvi A. Exercise-induced intermittent angina and ST-segment elevation in Prinzmetal’s angina. Eur Heart J. 1988;9:102–5.
    1. Nakao K, Ohgushi M, Yoshimura M, et al. Hyperventilation as a specific test for diagnosis of coronary artery spasm. Am J Cardiol. 1997;80:545–9.
    1. Sueda S, Fukuda H, Watanabe K, et al. Usefulness of accelerated exercise following mild hyperventilation for the induction of coronary artery spasm : comparison with an acetylcholine Test. Chest. 2001;119:155–62.
    1. Pepine CJ, Feldman RL, Conti CR. Action of intracoronary nitroglycerin in refractory coronary artery spasm. Circulation. 1982;65:411–4.
    1. Pepine CJ. Ergonovine echocardiography for coronary spasm: facts and wishful thinking. J Am Coll Cardiol. 1996;27:1162–3.
    1. Anderson JL, Adams CD, Antman EM, et al. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123:e426–579.
    1. Fox K, Garcia MA, Ardissino D, et al. Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J. 2006;27:1341–81.
    1. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44–122.
    1. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012;60:e44–e164.
    1. Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2012;60:645–81.
    1. Adlam D, Azeem T, Ali T, Gershlick A. Is there a role for provocation testing to diagnose coronary artery spasm? Int J Cardiol. 2005;102(1):1–7.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj