Successful Mitral Valve Repair for Papillary Muscle Rupture Caused by Coronary Spasm Induced by Myocardial Infarction / 日本心臓血管外科学会雑誌

Papillary muscle rupture, a complication of acute myocardial infarction, causes acute mitral valve regurgitation. However, to date, only a few articles have reported PMR associated with coronary spasm. In this article, we report the case of a 64-year-old woman who suffered posteromedial papillary muscle rupture caused by coronary spasm or Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA), and was successfully treated with mitral valve repair.

Cardiac arrest following reversal of muscle relaxation by pyridostigmine: A case report

The anticholinesterase pyridostigmine is usually used as a reversal agent of non-depolarizing muscle relaxants in general anesthesia. Most adverse muscarinic effects of anticholinesterases are controlled by anticholinergics; however, there is still a potential for fatal cardiac complications. We report a case of cardiac arrest associated with coronary vasospasm that developed during emergence from general anesthesia in a 61-year-old male patient undergoing uvulopalatopharyngoplasty with preoperatively undiagnosed coronary vasospastic angina. Anticholinesterases should be administered with caution for neuromuscular blockade reversal, especially in patients with coronary vasospastic angina.

Espasmo coronario dinámico: ¿Nueva entidad o presencia de un viejo problema? / Dynamic coronary spasm: New entity or presence of an old problem?

Es bien conocido el hecho de que la angioplastia coronaria transluminal percutánea (ACTP) y el implante de stent provocan daño endotelial. En ocasiones es tan severo que se manifiesta por vasoconstricción coronaria persistente, condicionando isquemia miocárdica (clínica, eléctrica y/o enzimática). Sin embargo, es posible que se manifieste de otra forma: espasmo coronario dinámico. Se presentan dos casos con varias similitudes entre sí: evolución tórpida con sospecha de oclusión del stent; intervencionismo con agresión endotelial (ultrasonido intracoronario e implante de stent); imagen angiográfica de espasmo arterial coronario dinámico, confundido con puente muscular. El espasmo coronario dinámico se puede definir como la vasoconstricción oclusiva dinámica de un segmento coronario epicárdico, en una arteria que ha sido sometida a intervencionismo. Habría que diferenciarlo del no reflujo, provocado por la oclusión total de la arteria intervenida del espasmo inducido por catéter, pero sobre todo, del puente muscular. En ambos casos se reportó como puente muscular, sin embargo, en el estudio diagnóstico no se observaba esta imagen. El motivo del presente trabajo es llamar la atención a la comunidad médica, específicamente al médico intervencionista, sobre una imagen que puede ser un factor pronóstico y terapéutico (tratamiento con calcio-antagonistas y nitratos, uso de marcadores séricos o seguimiento más estrecho), en la evolución de los pacientes sometidos a intervencionismo coronario.

The fact is that percutaneus transluminal coronary angioplasty (ACTP) and implants of stent induce vascular endothelial dysfunction. So severe that it is pronounced by persistent coronary vasoconstriction, conditioning ischemic complications (clinical, electrical and/or enzymatic). Nevertheless, it is possible that it is pronounced of another form: dynamic coronary vasospasm . We present two cases with several similarities: adverse outcome with suspicion of occlusion of stent; interventionism with endothelial aggression (intracoronary ultrasound and implant of stent); and angiographic image of dynamic coronary spasm, confused with muscular bridge. The dynamic coronary spasm can be defined as the dynamic occlusive vasoconstriction, of a epicardial coronary segment, in an artery that it has been put under interventionism. It would have to differentiate it from the no-reflow, caused by the total occlusion of the artery and persistent spasm induced by catheter. In both cases it was reported like muscular bridge, nevertheless, in the study diagnosis was not observed this image. Reason for the present work is to call the attention to the medical community, specifically to the interventionist doctor, on an image that can have a therapeutic and prognosis interest (treatment with calcium antagonists and nitrates, use of cardiac enzyme leves, and closer follow-up), in the evolution of the patient put under coronary interventionism.

Hyperthyroidism-associated coronary spasm: A case of non-ST segment elevation myocardial infarction with thyrotoxicosis / 老年心脏病学杂志（英文版）

Hyperthyroidism is associated with many heart diseases.Thyrotoxic state has a relationship with coronary spasm.We present a case of a non-menopausal woman with hyperthyroidism who complained of chest pain.The diagnosis of coronary spasm was confirmed by coronary angiography (CAG).She is treated well with anti-thyrotoxicosis and anti-anginal medication.We recommend not use CAG as the first diagnostic choice among the patients with medication-uncontrolled hyperthyroidism and chest pain.

Ventricular fibrillation due to coronary spasm at the site of myocardial bridge: A case report / 대한마취과학회지

Myocardial bridge is a congenital anomaly characterized by narrowing of some of the epicardial coronary arterial segments running in the myocardium during systole. Occasionally, the compression of a coronary artery by a myocardial bridge can be associated with the clinical manifestations of myocardial ischemia, and might even trigger a myocardial infarction or malignant ventricular arrhythmias. We report a case of ventricular fibrillation due to coronary spasm at the site of myocardial bridge. A 56-year-old man who had suffered from bronchial asthma was given remifentanil combined with sevoflurane in general anesthesia for endoscopic sinus surgery. During the surgery, ventricular fibrillation occurred following coronary spasm with bradycardia, hypotension, bronchospasm. we found myocardial bridge that coincided with an area of coronary spasm after coronary angiography.

A case of three-vessel coronary artery spasm presenting with aborted sudden cardiac death / 대한내과학회지

A 51-year-old female patient was referred to the emergency department with a 5-h history of resting chest pain. The patient, who had been diagnosed with variant angina six months previously, had not used her medications within two days of presentation. Electrocardiography (ECG) revealed a T wave inversion on lead I, AVL, and all precordial leads. Two hours later, the patient's chest pain was suddenly aggravated with an ST segment elevation noted from leads V2-6, leading to shock. Emergency management, including cardiopulmonary resuscitation (CPR), was initiated. Coronary angiography showed diffuse multifocal narrowing of three vessels; however, the vessels recovered following the intracoronary injection of nitroglycerin. The patient went into cardiac arrest two more times during continuous nitroglycerin infusion. The attacks were managed using CPR and sublingual nifedipine. Here, we describe a rare case of life-threatening three-vessel coronary vasospasm and its successful management with calcium channel blockers.

Severe Hypotension Caused by Coronary Spasm during Recovery from Combined Spinal Epidural Anesthesia: A case report / 대한마취과학회지

In order that anesthesiologists may reduce the anesthetic and surgical stress on the heart, they frequently use regional anesthesia in patients with coronary artery disease, even though there is no evidence that it reduce the incidence of myocardial ischemia. We report a case of life-threatening cardiovascular collapse that occurred in a 47 years old male patient at the emergence from regional anesthesia. He underwent open reduction and internal fixation for femur fracture under combined spinal epidural anesthesia.The cause of serious hypotension is suspected of myocardial ischemia on the basis of ST segment elevation on EKG. We considered that these cardiovascular events were due to coronary spasm.The possible inducing factors of coronary spasm were altered autonomic balance and arteriosclerotic change related endothelial dysfunction.

A Case of Myocardial Ischemia and Myocardial Injury Caused by Coronary Vasospasm Associated with Hyperthyroidism

There are many kinds of cardiac complications of hyperthyroidism such as angina pectoris, myocardial infarction, atrial fibrillation, congestive heart failure, heart block and sudden death. While angina is not uncommonly seen in association with hyperthyroidsm, it is rare that myocardial ischemia or infarction may be caused by coronary vasospasm. A 46 year-old man, who had been diagnosed with hyperthyroidism at the first admission, presented with chest pain. The serum thyroid hormone was still elevated. Serial ECGs showed significant ST elevation suggesting transmural ischemia, but coronary angiogram did not reveal any significant lesion. ECG at discharge was normalized without evidence of myocardial infartion. We report this case as an example of severe transmural ischemia with myocardial injury caused by coronary spasm associated with hyperthyroidism.

Patterns of Exercise-induced Coronary Spasm in Patients with Variant Angina: Results, Correlation with Clinical Features

BACKGROUND: Exercise-induced coronary spasm is occasionally recognized in patients with variant angina, but the patterns of exercise-induced coronary spasm and its relation to clinical features are still not clear. METHODS: Eight consecutive patients with variant angina without significant stenosis of the coronary artery performed serial treadmill exercise tests during early morning, late morning, and in the afternoon. The subjects repeated the tests after administration of atropine and doxazosin or phentolamine. RESULTS: (Upon drug administration), anginal episodes with ST-segment changes (elevation 5, depression 1) Occurred repeatedly in 6 of the 8 patients during early morning; the episodes occurred in only 2 patients during the afternoon exercise test. Four patients showed exercise-induced angina and ST-segment changes during early morning but not in the afternoon, and 2 of them showed mild episodes of exercise-induced angina and ST-segment changes during late morning. Three of the four patients had the characteristic clinical history of angina in early morning during usual activities but not during daytime activities despite the activities being more strenuous. Another 2 patients showed both exercise-induced ST-segment elevation and angina in early morning and afternoon, and they had the characteristic history of more episodes at night and in early morning but only occasionally in the daytime with or without relation to activity. One of the two patients showed intermittent ST-segment elevation during the exercise test. The other two patients had exercise-induced episodes neither in the early morning nor in the afternoon; they had a characteristic history of episodes only at night during sleep but never in the early morning nor in the daytime. Atropine did not suppress the exercise-induced angina in 4 of 5 patients studied. Doxazosin or phentolamine suppressed the exercise-induced episodes in 3 of 5 patients studied but aggravated spontaneous episodes in 3 patients. CONCLUSION: These data suggest that there's possibility of presence of different patterns of exercise-induced coronary spasm, which may be induced by different mechanisms from those in spontaneous episodes in patients with variant angina.

Successful Management of Intractable Coronary Spasm by a Coronary Stent

Variant angina is characterized by episodic angina due to spasm of an epicardial coronary artery at rest and concomitant transient ST elevation on electrocardiogram. While long-term survival of coronary spasm is usually excellent, but serious complications can be developed such as disabling pain, myocardial infarction, ventricular tachyarrhythmias, atrioventricular block and sudden cardiac death. We experienced 40 year-old man with intractable chest pain due to coronary artery spasm, who suffered from ventricular fibrillation and acute anterior myocardial infarction at the first admission. The patient underwent coronary angiogram, which revealed spontaneous focal spasm at the proximal left anterior descending coronary artery (LAD). He was treated by the combination of nitrate and calcium channel blocker. However, he complained of severe chest pain despite intensive medical therapy and visited emergency room 5 times during 8-month follow-up. We performed ergonovine coronary angiogram and intracoronary ultrasound, which revealed focal spasm at same site of proximal LAD with small amount of localized eccentric atheromatous plaque. Thus we placed coronary artery stent (3.0 x 24 mm GFX stent) at proximal LAD and his symptom was resolved after stenting. We performed follow-up coronary angiogram at 9 months after stenting and stent was patent without any stent recoil and in-stent restenosis.

The Effects of Tokishakuyaku-san and Mokuboi-to on Coronary Spasm in Swine / 日本東洋医学雑誌

Sixteen male swine were utilized to study the occurrence of acetylcholine (ACh) induced coronary spasm using catheters. The left anterior descending coronary arteries (LAD) of the swine were denudated by catheterization under anesthesia. The swine were divided into three groups and fed for four weeks. Group A received Tokishakuyaku-san (0.66g/kg/day; Tsumura Co. Ltd.; n=6) in addition to the basal rations; group B received Mokuboi-to (0.25g/kg/day; Tsumura Co. Ltd; n=5) in addition to the basal rations; and the control group were fed for four weeks on the basal rations alone. The Kampo formulas were administered via stomach tubes in groups A and B.<br>Coronary spasms induced by catheter administration of ACh (100-250μg) were evaluated by elevation of the ST segment as measured by electric cardiography, and vasoconstriction of the LAD as ascertained by cineangiography.<br>The ACh-induced coronary spasms were found to either be of the diffuse type or LAD segmental type. Coronary spasms were noted to occur at a frequency of 5/13 in group A, 5/12 in group B and 7/13 in the control group, without significant differences among the groups. Groups A and B, however, exhibited a tendency towards a decreased rate of coronary spasm (40%) when compared to the control group (53.8%).<br>The vasoconstriction rate (VCR) was also calculated, interpreted as a morphological index of spasms as proposed by Takeuchi (1974). The VCR was higher in the spastic segment of the LAD than in the non-spastic LAD. It was suggested that Tokishakuyaku-san and Mokuboi-to have antispasmodic effects and may reduce the occurrence rate of spasms in swine LAD.

Pharmacologically Inducible Coronary Vasospastic Changes in Patient with Ischemic Heart Diseases with Normal Angiogram or Insignificant Coronary Lesion and Its Relationships with Risk Factors

BAKGROUND AND PURPOSES: Spasm of epicardial coronary arteries has been shown to play an important role in the pathogenesis of ischemic heart diseases. Spasm occurs in angiographically normal coronary arteries or arteries with organic atherosclerotic lesion and can result in rest angina, exertional angina or even myocardial angina or even myocardial infarction. However, pathogenetic mechanism of coronary artery spasm still remains unclear. The purpose of present study is to investigate characteristics of pharmacologically induced spasm of epicardial coronary artery in patient with ischemic heart disease with normal coronary angiogram or insignificant coronary artery disease (<25% narrowing), and to determine the relationship of coronary risk factors with coronary artery spasm in these patients group. METHODS: One hundred patients(male 47, female 53, age : 19-75 years) with ischemic heart disease(stable angina, unstable angina, myocardial infarction) who had normal coronary angiogram or angiographically insignificant coronary artery stenosis(<25% narrowing) were included for pharmacological provocation test for coronary artery spasm. Acetylcholine(ACH) and Ergonovine(Erg) were given intracoronarily(IC) in incremental doses(Ach : A1, 20micro, A2 50microg, A3 100microg and Erg : E1 5microg, E2 10microg, E3 25microg) either into coronary artery concordant with ECG leads showing ischemic ST-T changes in exercise ECG and/or 24-hour ambulatory ECG, or otherwise into right coronary artery. Erg provocation test was done after completion of acetylcholine provocation test. Constriction of coronary artery by more than 50% induced by either or both of the drugs were analysed in terms of incidence, degree, location of spasm and relation to risk factors. Coronary vasodilatory reserve function was tested by IC Doppler method for those patients with no spasm of epicardial coronary artery but with chest pain and ST-segment changes during provocation test. Relationship of spasm with various risk factors were investigated. RESULTS: 1) Ach or Erg test were positivie in 50 patients(50%). Among 75 patients who were tested by both drug, both test were positive in 17 patients(22.6%), and negative in 39 patients(52%), and Ach test was positive but Erg test was negative in 15 patients(20%). : The responses of Ach and Erg test were concordant in 75% of patients, the sensitivity and specificity of Ach test with reference to Erg test were 81% and 72%, respectively. 2) The characteristic features of spasm induced by Ach or Erg is focal narrowing in 34 patients and diffuse narrowing in 16 patients. The sites of spasm were LAD(23 cases), RCA(19 cases), LCX(5 cases), and in 3 cases, both LAD and LCX were narrowed. 3) In 50 patients showing no spasm, the typical chest pain or EKG changes was noted in 6 cases(12%). Of 6 patients, coronary vasodilatory reserve was decreased in 4 cases(66.7%). 4) Number of smoker was larger among spasm positive group(42%) than those among spasm negative group(12%)(p<0.01). CONCLUSION: The findings we observed in a limited series of patients suggest that in patients with normal or insignificant coronary angiogram, coronary spasm plays a role in the pathogenesis of broad spectrum of ischemic heart disease and that in patients with no coronary spasm but chest pain and ST-segment changes, coronary vasodilatory reserve is impaired, causing angina pectoris. Smoking may be one of the risk factors for coronary arterial spasm.

Pharmacologically Inducible Coronary Vasospastic Changes in Patient with Ischemic Heart Diseases with Normal Angiogram or Insignificant Coronary Lesion and Its Relationships with Risk Factors

BAKGROUND AND PURPOSES: Spasm of epicardial coronary arteries has been shown to play an important role in the pathogenesis of ischemic heart diseases. Spasm occurs in angiographically normal coronary arteries or arteries with organic atherosclerotic lesion and can result in rest angina, exertional angina or even myocardial angina or even myocardial infarction. However, pathogenetic mechanism of coronary artery spasm still remains unclear. The purpose of present study is to investigate characteristics of pharmacologically induced spasm of epicardial coronary artery in patient with ischemic heart disease with normal coronary angiogram or insignificant coronary artery disease (<25% narrowing), and to determine the relationship of coronary risk factors with coronary artery spasm in these patients group. METHODS: One hundred patients(male 47, female 53, age : 19-75 years) with ischemic heart disease(stable angina, unstable angina, myocardial infarction) who had normal coronary angiogram or angiographically insignificant coronary artery stenosis(<25% narrowing) were included for pharmacological provocation test for coronary artery spasm. Acetylcholine(ACH) and Ergonovine(Erg) were given intracoronarily(IC) in incremental doses(Ach : A1, 20micro, A2 50microg, A3 100microg and Erg : E1 5microg, E2 10microg, E3 25microg) either into coronary artery concordant with ECG leads showing ischemic ST-T changes in exercise ECG and/or 24-hour ambulatory ECG, or otherwise into right coronary artery. Erg provocation test was done after completion of acetylcholine provocation test. Constriction of coronary artery by more than 50% induced by either or both of the drugs were analysed in terms of incidence, degree, location of spasm and relation to risk factors. Coronary vasodilatory reserve function was tested by IC Doppler method for those patients with no spasm of epicardial coronary artery but with chest pain and ST-segment changes during provocation test. Relationship of spasm with various risk factors were investigated. RESULTS: 1) Ach or Erg test were positivie in 50 patients(50%). Among 75 patients who were tested by both drug, both test were positive in 17 patients(22.6%), and negative in 39 patients(52%), and Ach test was positive but Erg test was negative in 15 patients(20%). : The responses of Ach and Erg test were concordant in 75% of patients, the sensitivity and specificity of Ach test with reference to Erg test were 81% and 72%, respectively. 2) The characteristic features of spasm induced by Ach or Erg is focal narrowing in 34 patients and diffuse narrowing in 16 patients. The sites of spasm were LAD(23 cases), RCA(19 cases), LCX(5 cases), and in 3 cases, both LAD and LCX were narrowed. 3) In 50 patients showing no spasm, the typical chest pain or EKG changes was noted in 6 cases(12%). Of 6 patients, coronary vasodilatory reserve was decreased in 4 cases(66.7%). 4) Number of smoker was larger among spasm positive group(42%) than those among spasm negative group(12%)(p<0.01). CONCLUSION: The findings we observed in a limited series of patients suggest that in patients with normal or insignificant coronary angiogram, coronary spasm plays a role in the pathogenesis of broad spectrum of ischemic heart disease and that in patients with no coronary spasm but chest pain and ST-segment changes, coronary vasodilatory reserve is impaired, causing angina pectoris. Smoking may be one of the risk factors for coronary arterial spasm.

The Response of Coronary Artery Diameter to Acetylcholine in Patients with or Without Minimally Diseased Coronary Artery*

BACKGROUND: Coronary artery spasm plays an important role in the pathogenesis of not only variant angina but also other forms of angina,acute myocardial infarction, and sudden death. However precise mechanisms by which coronary spasms occur remains unknown. The role of increased coronary artery tone as a part of pathogenesis of conary spasm and relation to the severity of coronary artery disease are still controversial. Thus we underwent this study to investigate the role of increased coronary artery tone as a part of pathogenesis of conary spasm and realtion to the severity of coronary artery disease. METHODS: Intracoronary acetylcholine and isosorbide dintrate were used as a spasm-provocative agent and vasodilator respectively. We analyzed 176 vessels(69 right coronary artery, 58 left anterior descending coronary artery, 49 left circumflex coronary artery) of 75 patients admitted for evaluation of chest pain syndrome. Among the 176 vessels, spasm occurred in 39 vessels of 25 patients. RESULTS: 1)Coronary artery spasm occured in 30.4%(21/69), 17.2%(10/58), 16.3%(8/49) of right coronary artery, left anterior descending coronary artery, left circumflex coronary artery respectively. 2) There is no relationship between angiographically visible minimal coronary artery disease and occurrence of spasm provoked by acetylcholine. 3) There was no significant difference of coronary risk factor predicting coronary spasm between two groups. 4) There is more significant % vasodilation by isosorbide dintrate(ISDDN) occurred din both the spastic and nonspastic arterial segment of vasospastic angina group than no spasm group(30.2%, 28.4% vs 14.2%, p<0.05). 5) Degree of % vasodilation by ISDN was more significantly larger in vasospastic angina group than no spasm group despite the presence of same amount of angiographically visible minimal coronary artery disease(38.3% vs 12.5%, p<0.05). CONCLUSION: These findings suggests that the occurrence of conronary artery spasm is not related to minimal coronary artery disease. Increased coronary artery tone observed only in vasospastic angina group may be part of pathogenesis of coronary spasm.

A Case of Refractory Variant Angina Relieved by Clonidine

Coronary spasm may be induced by a variety of physiologic and pharmacologic stimuli but specific receptor blockade has not been consistently shown to prevent the attacks. Most patients with variant angina respond well to treatment with calcium antagonists and nitrates. A small proportion of patients are refractory to this therapy. We report a case of the patient with a 9-year-history of variant angina who has been refractory to high doses of calcium antagonists and nitrates. The repeated addition of clonidine was consistently effective in abolishing both symptoms and objective evidence of myocardial ischemia in this particular patient.

Acetylcholine Induced Coronary Spasm in Patients with Acute Myocardial Infarction with Angiographically Normal or Near Normal Coronary Arteries

Recent studies suggest that coronary endothelial dysfunction in atherosclerosis may contribute to the predisposition both for coronary spasm as well as for thrombus formation. The integrity of at least one aspect of endothelial function can be assessed by the intracoronary administration of acetylcholine. Eleven(13.4%, mean age 48+13, male 11) out of 82 consecutive patients with acute myocardial infarction showed angiographically normal or near normal coronary arteries at 7~10 in-hospital days. Ten(91%) had history of heavy smoking and 7 patients(64%) had no history of previous angina. Anterior myocardial infarction was in 8 and inferior in 3 patients. After intracoronary administration of acetylcholine(incremental dose of 20, 50ug for the right and 20, 50, 100ug for the left), 9(82) of 11 infarct related arteries showed total or subtotal occlusion, but only in 3(17%) out of 18 non-infarct related arteries of 10 patients. Multivessel spasm was noticed in 3. Ergonovine test(graded doses of 0.05, 0.1 and 0.2 mg intravenously) was performed 30 minutes after completion of acetylcholine test in 5 patients. In 1 patients, acetylcholine test was positive and but ergonovine test was negative. Conclusion : 1) Eleven(13.4%) out of 82 patients with acute myocardial infarction had angiographically normal coronary arteries. 2) Ach positive responses of infarct-related arteries are more frequent(82%) than that of non-infarct related arteries(17%), suggesting that the infarction might be related to coronary artery spasm. 3) Positive Ach responses of non-infarct related arteries occurred in 30% of Patients. 4) Ach and Erg induced vasospasm developed at the same site in 5, which suggests that local hyperreactivity might be related to spasm.