Life Threatening Complication of Self-made Remedy for Controlling High Blood Pressure-Coronary Artery Vasospasm Associated with Iatrogenic Thyrotoxicosis

We report the case of a middle aged woman who was previously diagnosed with hypertension. She had been drinking a kelp concentrate solution daily for her hypertension instead of taking the prescribed medicine due to her personal beliefs about the kelp solution. As a consequence, she experienced vasospastic angina complicated by myocardial infarction and cardiogenic syncope resulting from iatrogenic thyrotoxicosis. Complementary medicine is widely used by the general population. However, there is still a lack of evidence regarding their efficacy and safety. This case shows that inadequate use of complementary medicine could have no effect and may even be harmful. In patients with chronic diseases such as hypertension, self-care in the form of life style modification, home blood pressure monitoring and medial adherence are important for disease management.

Predictive Factors for Long-term Clinical Outcomes in Patients with Variant Angina / 대한내과학회지

BACKGROUND/AIMS: The incidence of variant angina (VA) is relatively high in Korea compared with western countries, but its long-term clinical outcomes are not well defined. METHODS: Patients who underwent ergonovine provocation tests at the cardiac catheterization laboratory of Chonnam National University Hospital between 1996 and 2011 were enrolled in this study (n = 1162). Of them, 686 patients with positive ergonovine provocation tests were divided into two groups: patients with cardiac events (Group I: 153 patients, 52.4 +/- 11.0 years, M: F = 103: 50) and those without (Group II: 533 patients, 51.6 +/- 10.7 years, M: F = 350: 183). The mean follow-up duration was 40.2 +/- 38.0 months. Cardiac events were defined as cardiac death, recurrent ischemia, rehospitalization, myocardial infarction, and follow-up angiography. Clinical findings, laboratory and coronary angiographic characteristics were compared between the groups. RESULTS: A history of smoking was more common in Group I than in Group II (45.8% vs. 36.3%, p = 0.037). The levels of low-density lipoprotein cholesterol (119.4 +/- 35.3 vs. 111.1 +/- 32.2 mg/dL, p = 0.010) were higher in Group I than in Group II. According to Cox proportional hazard regression analysis, the major predictive factor for cardiac events during clinical follow-up was smoking (HR 1.80, 95% CI 1.036-3.126, p = 0.037). CONCLUSIONS: A history of smoking was the only independent risk factor for cardiac events during a long-term clinical follow-up in Korean patients with variant angina.

C-Type Natriuretic Peptide as a Surrogate Marker in Variant Angina Pectoris

BACKGROUND AND OBJECTIVES: The purpose of this study was to assess the value of C-type natriuretic peptide (CNP) as a surrogate marker for detection of coronary artery spasm in variant angina pectoris (VAP). SUBJECTS AND METHODS: Sixty-six patients (mean age: 51+/-11 years, M : F=40 : 26) who underwent coronary angiography on suspicion of angina and who were diagnosed with VAP by the acetylcholine-induced spasm provocation test (SPT) were enrolled and divided into a SPT (-) group (n=23) and a SPT (+) group (n=43). Concentrations of CNP and other markers were determined by immunoassay in both groups. RESULTS: Plasma CNP and creatine kinase myoglobin band (CK-MB) concentrations were significantly increased in the SPT (+) group relative to the SPT (-) group (CNP, 5.268+/-1.800 pg/mL vs. 3.342+/-1.150 pg/mL, p=0.002; CK-MB, 2.54+/-1.03 ng/dL vs. 1.86+/-0.96 ng/dL, p=0.019, respectively) while plasma high sensitivity C-reactive protein (hs-CRP) and N-terminal pro-brain natriuretic peptide (NT pro-BNP) concentrations were not significantly different between the SPT (-) group and SPT (+) group (hs-CRP, 2.76+/-4.99 mg/L vs. 3.13+/-4.88 mg/L, p=0.789; NT pro-BNP, 49+/-47 pg/mL vs. 57+/-63 pg/mL, p=0.818, respectively). Plasma CNP concentration was independently associated with the VAP via SPT {odds ratio: 2.014 (95% confidence interval: 1.016-3.992), p=0.045}. A CNP cut-off value of 4.096 pg/mL was found to have a sensitivity of 68.2% and a specificity of 40.0% for predicting the probability of VAP via SPT. CONCLUSION: Increased plasma CNP concentration in patients with VAP may have an impact on the regulation of endothelial function in accordance with the progression of atherosclerosis. Further analysis is warranted to develop clinical applications of this finding.

Does a Negative Ergonovine Provocation Test Truly Predict Freedom from Variant Angina?

Ergonovine provocation test is known to be very sensitive for diagnosing variant angina. The patient described in this study initially presented with atypical chest pain and underwent coronary angiography and ergonovine provocation tests, which were negative. The patient was subsequently prescribed a proton pump inhibitor and prokinetics for pain relief, but then presented with acute myocardial infarction and cardiogenic shock due to coronary artery vasospasm 5 years later. This case suggests that ergonovine provocation test generates false negative results, which can lead to unwanted outcomes. Even with a negative ergonovine provocation test, prescription of calcium channel blockers or nitrates should be considered in patients with a clinical history suggestive of variant angina.

Significant Response to Lower Acetylcholine Dose Is Associated with Worse Clinical and Angiographic Characteristics in Patients with Vasospastic Angina

BACKGROUND AND OBJECTIVES: The intracoronary injection of acetylcholine (Ach) has been shown to induce coronary spasms in patients with variant angina. Clinical significance and angiographic characteristics of patients with a significant response to lower Ach dosages are as-yet non-clarified compared with patients responding to higher Ach doses. SUBJECTS AND METHODS: A total of 3034 consecutive patients underwent coronary angiography with Ach provocation tests from January 2004 to August 2010. Ach was injected in incremental doses of 20, 50, 100 microg into the left coronary artery. Significant coronary artery spasm was defined as focal or diffuse severe transient luminal narrowing (>70%) with/without chest pain or ST-T change on the electrocardiogram (ECG). We compared the clinical and angiographic characteristics of patients who responded to a lower Ach dose (20 or 50 microg, n=556) to those that responded to a higher Ach dose (100 microg, n=860). RESULTS: The baseline clinical and procedural characteristics are well balanced between the two groups, except diabetes was higher in the lower Ach dose group and there were differences in medication history. After adjusting for confounding factors, the lower Ach dose group showed more frequent temporary ST elevation and atrioventricular block on the ECG. Furthermore, the group of patients who responded to the lower Ach dose was associated with a higher incidence of baseline and severe spasm than those who responded to a higher Ach dose. CONCLUSION: Patients with a significant response to a lower Ach dose were associated with more frequent ST elevation, baseline spasm, and more severe spasm compared with those who responded to a higher Ach dose, suggesting more intensive medical therapy with close clinical follow-up is required for those patients.

Clinical characteristics of variant angina patients with or without fixed coronary stenosis / 中华全科医师杂志

Seventy-one patients with variant angina (VA) admitted in the Cardiology Department from January 2003 to March 2011,were divided into non-stenosis group (stenosis ＜ 50％,n =43) and stenosis group (stenosis ≥50％,n =28) according to the degree of stenosis.The differences of the risk factors,clinical manifestations,electrocardiogram,echocardiogram and laboratory examinations between these two groups were compared.The average age of patients in stenosis group 58 ± 8 y was higher than that in non-stenosis group (52 ± 9 y,t =2.43,P =0.02).Other risk factors,including male gender,smoking,hypertension,diabetes mellitus and lipid disorder did not show any differences between the two groups.Percentage of patients with angina pectoris lasting less than 5 min was higher in stenosis group (x2 =5.98,P =0.02),while percentage of effort angina,seeking medical consultation ≤ 6 months of onset and hemodynamic disorders showed no difference.Laboratory examinations had no differences.It is difficult to determine whether the VA patient has fixed coronary stenosis by analyzing the risk factors,clinical manifestations and laboratory examinations; to determine the fixed coronary stenosis coronary angiography is necessary.

A Case of Acute Myocardial Infarction with Resolution of ST-Segment Elevation Immediately after Ventricular Defibrillation / 대한내과학회지

A 38-year-old man presented with typical squeezing-type anterior chest pain. An initial electrocardiogram (ECG) showed prominent ST-segment elevation (V1-V4 lead, 3 mm). Suddenly, the patient fell unconscious and had no pulse. At that time, the ECG showed polymorphic ventricular fibrillation (VT). After direct current (DC) cardioversion, the patient regained vital signs and defibrillation converted the VT into an accelerated idioventricular rhythm with resolution of the ST-segment elevation. The patient was referred to our hospital for close observation and further evaluation. At our hospital, an ECG showed normal sinus rhythms and cardiac enzymes were within normal limits. We diagnosed the patient with variant angina rather than ST elevation myocardial infarction (STEMI), because his clinical manifestations were quite distinct; ST-segment elevations disappeared slowly at the reperfusion stage. However, the patient's final diagnosis was STEMI because coronary angiography showed severe eccentric tubular stenosis (85%) with remnant thrombus in the middle left anterior descending artery. Defibrillation likely removed the thrombus, which led to STEMI.

A Case of Variant Angina Developing Transient Collateral Circulation During Vasospasm

Variant angina is characterized by spontaneous episodes of angina, usually occurring in the morning and having ST segment elevation on the electrocardiogram. However, in the case presented here, vasospasm and angina was shown by ergonovine without ST elevation. The patient was a 60-year-old man who presented with a 2-year history of frequent chest pain. There were no abnormalities in coronary angiography. When ergonovine (100 microg) was injected, total occlusion of the proximal right coronary artery was seen, without ST elevation at the electrocardiogram. The cause was collateral from left anterior descending artery to distal right coronary artery at the left coronary angiography. Therefore, in a patient with variant angina without ST elevation, a transient collateral circulation during vasospasm should be considered.

Alteration of Ventricular Repolarization by Intracoronary Infusion of Normal Saline in Patients With Variant Angina

BACKGROUND AND OBJECTIVES: During coronary angiography and interventional procedures, catheters that are engaged in a coronary ostium are routinely flushed, typically with normal saline, to expel blood from the catheter or to inject a pharmacologic agent. Saline contains sodium and chloride ions. Such injections may affect the electrophysiologic properties of the myocardium; however, the effect of normal saline on ventricular repolarization has not been established in patients with variant angina. SUBJECTS AND METHODS: We studied 51 consecutive patients with variant angina. Five mL of normal saline (NS) or 5% dextrose solution (DW) were infused into the left coronary artery in random order. We measured the heart rate, QT interval, and T-wave amplitude using Mac-Lac 5.2. RESULTS: The baseline clinical characteristics were not different between the NS {n=30 (14 males); mean age, 56+/-10 years} and the 5% DW groups {n=21 (7 males); mean age, 59+/-10 years}. The changes in the mean corrected QT (QTc) interval were significantly increased at the time of infusion of NS compared to 5% DW (45.1+/-30.3 vs. 20.9+/-23.3 ms, p=0.004). There was a T-wave amplitude change >0.2 mV in at least one-lead in 27 patients (90.0%) during NS infusion compared to 7 patients (33.3%) during 5% DW infusions (p=0.001). No significant changes in heart rate and blood pressure were noted during of the infusions. CONCLUSION: NS was associated with prolongation of ventricular repolarization in patients with variant angina.

A case of coronary vasospasm-induced ventricular fibrillation without significant coronary artery disease / 대한내과학회지

Coronary vasospasm plays an important role in the pathogenesis not only of variant angina, but also of ischemic heart disease in general, including other forms of angina pectoris, acute myocardial infarction, and sudden death. Vasoactive events leading to an acute reduction in regional myocardial flow in the presence of a normal or previously compromised circulation are a common cause of arrhythmias. However, coronary vasospasm-induced electrical and mechanical complications are rarely reported in patients with angiographically normal or near-normal coronary arteries. This paper presents our experience with a patient presenting with coronary vasospasm-associated ventricular fibrillation without findings of significant coronary artery disease.

A case of coronary vasospasm-induced ventricular fibrillation without significant coronary artery disease / 대한내과학회지

Coronary vasospasm plays an important role in the pathogenesis not only of variant angina, but also of ischemic heart disease in general, including other forms of angina pectoris, acute myocardial infarction, and sudden death. Vasoactive events leading to an acute reduction in regional myocardial flow in the presence of a normal or previously compromised circulation are a common cause of arrhythmias. However, coronary vasospasm-induced electrical and mechanical complications are rarely reported in patients with angiographically normal or near-normal coronary arteries. This paper presents our experience with a patient presenting with coronary vasospasm-associated ventricular fibrillation without findings of significant coronary artery disease.

Angina ao repouso provocada por espasmo coronariano: mito ou realidade? / Rest angina caused by coronaryspasm: myth or reality?

A Angina de Prinzmetal foi descrita em 1959, sendo caracterizada por ataques recorrentes de dor precordial ao repouso associados à elevação transitória do segmento S-T. Documentamos o caso de um homem, 58 anos, tabagista, previamente livre de sintomas coronarianos, que foi admitido com dor retroesternal aguda. O eletrocardiograma mostrou elevação transitória do segmento S-T nas derivações V1 a V3, que retornou à linha de base após cessar a dor. O nível sérico das enzimas cardíacas estava normal. O ecocardiograma não apresentou alterações segmentares da contratilidade do ventrículo esquerdo e a coronariografia demonstrou obstrução severa no terço proximal da artéria descendente anterior e na artéria diagonal. Foi tratado com nitrato, diltiazem e angioplastia com stent e não apresentou novos sintomas. Foi confirmado o diagnóstico de espasmo coronariano. Cabe ressaltar a importância de se incluir a Angina de Prinzmetal no diagnóstico diferencial da Síndrome Coronariana Aguda para que novos casos sejam precocemente diagnosticados.

Prinzmetal's Angina was described in 1959. It is characterized by recurrent episodes of spontaneous chest pain associated with transient ST-segment elevation. We report herein a case of a 58 year-old previously healthy man, who was admitted with acute retrosternal pain. Smoking was the only risk factor for atherosclerotic disease. The electrocardiogram showed transient ST-segment elevations from V1 toV3 leads. The cardiac enzymes tested normal. The echocardiogram didn't exhibit any abnormality in the left ventricular contractility and the coronary angiography revealed severe occlusion in both proximal part of the left anterior descending artery and the diagonal artery. The patient received nitrate and diltiazen, and the coronary lesions were treated with balloon angioplasty plus stenting. The follow up was uneventful. The diagnosis of variant angina (Prinzmental's angina) was made. In conclusion, Prinzmetal's Angina should always be included in the differential diagnosis of Acute Coronary Syndrome, so that new cases can be early diagnosed and treated.

Long-Term Prognosis and Clinical Characteristics of Patients With Variant Angina

BACKGROUND AND OBJECTIVES: The overall prognosis of patients with vasospastic angina (VA) is relatively good. However, the long-term prognosis and its influencing factors are not well understood in Korean patients. SUBJECTS AND METHODS: Between August 1996 and January 2007, 256 consecutive patients with VA were reviewed (215 men, 53+/-9 years). Coronary spasm was confirmed via intravenous ergonovine provocation in all study patients during coronary angiography. Major adverse cardiac events (MACEs) were defined as myocardial infarction (MI), resuscitation from cardiac arrest, or repeat hospitalization due to recurrent angina. RESULTS: The 256 patients were followed for an average of 59 months (range, 5 months to 11 years). Thirty-one patients (12.1%) were lost to follow-up. Cardiac deaths occurred in 6 patients (2.3%), non-fatal MIs occurred in 3 patients (1.2%), and MACEs occurred in 52 patients (20.3%). The rates of survival at 1, 3, and 5 years were 99%, 97%, and 97%, respectively, and the rates of MI-free survival at 1, 3, and 5 years were 99%, 96%, and 95%, respectively. Rates of MACE-free survival at 1, 3, and 5 years were 91%, 81%, and 62%, respectively. MI at initial presentation and current smoking were factors significantly associated with MACEs; these factors were also independent predictors of MACE-free survival. CONCLUSION: Despite treatment with calcium channel blockers, recurrent episodes of angina were frequently observed, whereas sudden cardiac death and non-fatal MI were rare. Smoking and myocardial infarction at admission were independent risk factors for cardiac death, non-fatal MI, and repeat hospitalization due to recurrent angina in patients with variant angina.

Changes of Coronary Blood Flow in Vasospastic Angina under Cold Stimulation by Transthoracic Doppler Echocardiography

This study was done to evaluate changes of microvascular function under cold stimulation by measuring coronary flow velocities (CFVs) in vasospastic angina (VA) patients using transthoracic Doppler echocardiography (TTDE). 14 patients with VA and 15 healthy controls were included. CFVs were measured at the distal left anterior descending coronary artery by TTDE at baseline and under cold stimulation. Hyperemia was induced by intravenous adenosine infusion (140 microgram/kg/min). At baseline, CFVs and coronary flow reserve (CFR) were not different between controls and VA patients. Under cold stimulation, the degree of increment of CFV with adenosine was lower in VA patients than in controls. Comparing baseline with cold stimulation, coronary flow reserve (CFR) increased (3.1 +/-0.7 to 3.8 +/-1.0, p=0.06) in controls. In contrast, in VA patients, CFR was decreased (2.8 +/-0.9 to 2.6 +/-0.7, p=0.05) and coronary vascular resistance index markedly increased (0.35 to 0.43, p=0.01). Throughout the study, no patient experienced chest pain or ECG changes. In VA patients, CFR was preserved at baseline, but coronary blood flow increase in response to cold stimulation was blunted and CFR was decreased. These findings suggest that endothelial dependent vasodilation is impaired at the coronary microvascular and the epicardial artery level in VA under cold stimulation.

A Case of Coronary Vessel Anomaly of the Left Circumflex Artery Originating from the Right Coronary Artery with Variant Angina

Coronary vessel anomaly is a rare disease, with an incidence of about 0.6-1.3% of patients receiving coronary angiography. The ischemia in coronary vessel anomalies is due in most cases to atherosclerosis or compression of the coronary artery by a great vessel, but occasionally spasm of a coronary vessel anomaly is responsible for the pathogenesis of chest pain and myocardial ischemia. A 64-year-old female presented with a one-year history of effort angina. The left circumflex artery originated from the proximal right coronary artery. There was no atherosclerotic lesion in the right and left coronary arteries, but a focal spasm in the right coronary artery by ergonovine. In a patient with chest pain and coronary artery anomaly, if there is no coronary atherosclerosis, abnormal course or compression, the spasm test of the coronary artery should be documented.

The Risk Factors of Vasospastic Angina

BACKGROUND AND OBJECTIVES: The causes of vasospastic angina are not well known. We attempted to elucidate the risk profiles of Korean patients with vasospastic angina. SUBJECTS AND METHODS: The risk profiles were analyzed in 181 patients with vasospastic angina (VA), 1533 patients with obstructive coronary artery disease (CAD) who underwent coronary angiography at Samsung Seoul Hospital, and 455 normal control subjects, sex and age matched to the VA group and selected from the Health Promotion Center of Samsung Seoul Hospital. The male to female ratio was significantly higher in the VA group (4.6:1) than the obstructive CAD group (2.7:1). The mean age of the VA group (52.2+/-10.7 years) was significantly younger than the mean age of the obstructive CAD group (59.0+/-10.6 years) (p<0.01). Additionally, the smoking rate was significantly higher in the VA group (49.2%) as compared with the obstructive CAD group (43.1%) (p<0.01). Other major risk factors such as hyperlipidemia, hypertension and diabetes mellitus were significantly more prevalent in the obstructive CAD group than the VA group. Among the obstructive CAD group, a subgroup of Q-wave myocardial infarction (MI) showed a significantly higher smoking rate (59.3%) as compared with VA group (49.2%) (p<0.01). CONCLUSION: The VA group showed a higher prevalence in males and younger subjects as compared with the obstructive CAD group, and smoking appeared to be the most important risk factor for VA.

The Study of Coronary Spasm by Follow-up Coronary Angiography in Variant Angina

BACKGROUND AND OBJECTIVES: The therapeutic duration of variant angina is controversial. This study sought to determine the remission rates for coronary artery spasms, the factors associated with remission and the changes in spasm sites. SUBJECTS AND METHODS: Fifty-eight patients were enrolled in the study. Initial, and follow-up, coronary angiographies (CAG), with ergonovine stimulation tests, were performed. Paired CAG were performed at a mean interval of 27+/-17 months. Medication was stopped 3 days prior to the follow-up CAG, and the occurrence of chest pain during these 3 days was studied. Coronary spasms were confirmed by follow-up CAG. Any changes, and the diameters, of spasm sites were analyzed on each paired CAG. RESULTS: The remission rate of coronary spasms was 24% (14 patients), when the smoking group (49 patients) stopped smoking (31 patients), the remission rate was 29% (9 patients). In the current smoking group (18 patients), the remission rate was 6% (1 patient, p=0.05). 31 patients had chest pains after stopping medication prior to their follow-up CAG. Of those patients, 1 patient had a remission (3%). Among another 27 patients with no chest pain, 13 patients had a remission (48%, p<0.001). In 28 out of 44 patients (64%, non-remission), fluctuations in spastic locations were observed at the follow-up CAG. The interval changes in the diameter of the spasm sites were not significant. CONCLUSION: The non-chest pain group showed higher remission rates, but lack of chest pain did not identify the loss of coronary spasm. Atherosclerosis at spasm sites did not progress, as confirmed by the paired CAG in our study.