Coronary Computed Tomography Angiography for the Diagnosis of Vasospastic Angina: Comparison with Invasive Coronary Angiography and Ergonovine Provocation Test

OBJECTIVE: To investigate the diagnostic validity of coronary computed tomography angiography (cCTA) in vasospastic angina (VA) and factors associated with discrepant results between invasive coronary angiography with the ergonovine provocation test (iCAG-EPT) and cCTA. MATERIALS AND METHODS: Of the 1397 patients diagnosed with VA from 2006 to 2016, 33 patients (75 lesions) with available cCTA data from within 6 months before iCAG-EPT were included. The severity of spasm (% diameter stenosis [%DS]) on iCAG-EPT and cCTA was assessed, and the difference in %DS (Δ%DS) was calculated. Δ%DS was compared after classifying the lesions according to pre-cCTA-administered sublingual nitroglycerin (SL-NG) or beta-blockers. The lesions were further categorized with %DS ≥ 50% on iCAG-EPT or cCTA defined as a significant spasm, and the diagnostic performance of cCTA on identifying significant spasm relative to iCAG-EPT was assessed. RESULTS: Compared to lesions without SL-NG treatment, those with SL-NG treatment showed a higher Δ%DS (39.2% vs. 22.1%, p = 0.002). However, there was no difference in Δ%DS with or without beta-blocker treatment (35.1% vs. 32.6%, p = 0.643). The significant difference in Δ%DS associated with SL-NG was more prominent in patients who were aged < 60 years, were male, had body mass index < 25 kg/m2, and had no history of hypertension, diabetes, or dyslipidemia. Based on iCAG-EPT as the reference, the per-lesion-based sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cCTA for VA diagnosis were 7.5%, 94.0%, 60.0%, 47.1%, and 48.0%, respectively. CONCLUSION: For patients with clinically suspected VA, confirmation with iCAG-EPT needs to be considered without completely excluding the diagnosis of VA simply based on cCTA results, although further prospective studies are required for confirmation.

Successful Treatment of Coronary Spasm with Atherosclerosis Rapidly Progressing to Acute Myocardial Infarction in a Young Woman

Variant angina pectoris (VAP) is a special type of unstable angina with coronary artery spasm as the main pathogenesis, characterized by resting chest pain, and transient ST segment dynamic changes. The development of acute myocardial infarction is not uncommon. We report a case of a 49-year-old female patient diagnosed with VAP at 2 years before who suddenly suffered severe chest pain. Troponin-I was elevated. Immediate coronary angiography showed near-total occlusion in the proximal left anterior descending artery, which was not fully dilated despite use of intracoronary nitroglycerin. Intravascular ultrasound showed focal significant stenosis with a large amount of plaque at the site of spasm and the lesion was successfully treated with drug-eluting stent placement. Intravascular imaging may be instrumental in high-risk patients with VAP who suffer recurrent chest pain despite intensive anti-spasm medications.

Elevación transitoria del ST, angina variante de Prinzmetal / Transitory ST elevation, Prinzmetal angina

La angina variante de Prinzmetal es una enfermedad poco frecuente en Colombia, pero con alto riesgo de complicaciones sino se diagnostica e inicia su manejo precozmente. Así mismo, es una de las causas de elevación del segmento ST en el electrocardiograma en pacientes con dolor torácico. Se expone el caso de una paciente con enfermedad vasoespástica y cuya presentación clínica simuló una infarto agudo de miocardio y luego de realizar los estudios diagnósticos se pudo descartar éste y dar el tratamiento adecuado.

Prinzmetal variant angina is an uncommon disease in Colombia, it have high risk of complications if is not diagnosed early and a rapid treatment starter. Also, it is one of the causes of ST segment elevation on the electrocardiogram in patients with chest pain in the emergency department. We describe the case of a patient with vasospastic disease whose clinical presentation simulates a heart attack and after diagnostic studies that allowed dismiss this and, the proper treatment was given.

Cardiac arrest after sugammadex administration in a patient with variant angina: a case report / 대한마취과학회지

A 76-year-old man with no notable medical history was scheduled for a robot-assisted radical prostatectomy. After the operation, he was given sugammadex. Two minutes later, ventricular premature contraction bigeminy began, followed by cardiac arrest. Cardiac arrest occurred three times and cardiopulmonary resuscitation was done. The patient recovered after the third cardiopulmonary resuscitation and was transferred to the intensive care unit. Coronary angiography was done on postoperative day 1. The patient was diagnosed with variant angina and discharged uneventfully on postoperative day 8.

Ventricular Tachycardia Associated Syncope in a Patient of Variant Angina without Chest Pain

A 68-year-old man was admitted for a syncope workup. After routine evaluation, he was diagnosed with syncope of an unknown cause and was discharged from the hospital. He was readmitted due to dizziness. On repeated Holter monitoring, polymorphic ventricular tachycardia was detected during syncope. We performed intracoronary ergonovine provocation test; severe coronary spasm was induced at 70% stenosis of the proximal left anterior descending artery. The patient was treated with percutaneous coronary intervention. We present a rare case of syncope induced by ventricular arrhythmia in a patient with variant angina without chest pain.

Ventricular Tachycardia Associated Syncope in a Patient of Variant Angina without Chest Pain

A 68-year-old man was admitted for a syncope workup. After routine evaluation, he was diagnosed with syncope of an unknown cause and was discharged from the hospital. He was readmitted due to dizziness. On repeated Holter monitoring, polymorphic ventricular tachycardia was detected during syncope. We performed intracoronary ergonovine provocation test; severe coronary spasm was induced at 70% stenosis of the proximal left anterior descending artery. The patient was treated with percutaneous coronary intervention. We present a rare case of syncope induced by ventricular arrhythmia in a patient with variant angina without chest pain.

Recurrent Cardiac Arrest during a Nontransplant Operation Due to Variant Angina in a Liver Transplantation Patient / 대한이식학회지

We report a case of recurrent cardiac arrest during a nontransplant operation in a liver transplant recipient with prior cardiac arrest during liver transplantation. A 45-year-old man who experienced cardiac arrest for 17 minutes during the preanhepatic phase of liver transplantation–which was performed 34 months ago–did not survive the recurrent cardiac arrest during portal venoplasty. Variant angina was not suspected for the first cardiac arrest; however, myocardial infarction by coronary vasospasm was revealed to be the cause of the second cardiac arrest.

Recurrent myocardial infarction secondary to Prinzmetal's variant angina

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

Coronary Spastic Angina and Life Threatening Arrhythmia despite Nitroglycerine Infusion / 이화의대지

Variant angina pectoris is characterized by chest symptoms at rest and transient ST elevation on the electrocardiography due to coronary artery spasm. Although most patients with coronary spasm respond well to medical treatment with vasodilators such as calcium channel blockers and nitrates, some patients show intractable attack of coronary vasospasm despite standard medical therapy. We experienced 50-year-old woman with intractable chest pain due to coronary artery spasm, who suffered from ventricular fibrillation despite continuous intravenous nitrate therapy.

Clinical studies of Sangi Tonglero decoction on dynamic electrocardiogram in patients with variant angina pectoris / 中国生化药物杂志

Objective To investigate the effect of Sangi Tonglero decoction on dynamic electrocardiogram and clinical results, in order to improve the level of clinical treatment. Method 110 Patients with variant angina pectoris in February 2010 to February 2013 were selected and divided randomly into two groups. 55 patients in control group were given amlodipine treatment , the other in observation group were added Sangi Tonglero decoction beside amlodipine treatment. The differences in electrocardiogram and clinical effects between two groups after treatment were compared. Results The clinical results of dynamic electrocardiogram and angina were showed that the efficiency rate and total efficiency rate in observation group were significantly higher than that in control group(P<0.05). The difference of lipid levels, blood rheology indicators between two groups after treatment were statistically significant (P<0.05). Conclusion Dynamic electrocardiogram is a preferred method of checking variant angina pectoris , and Sangi Tonglero decoction can significantly improve the therapeutic effect .

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

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

Effects of Low Dose versus High Dose Statin Therapy on the Changes of Endothelial Function and Carotid Intima-Media Thickness in Patients with Variant Angina

BACKGROUND: To compare the effects of low dose and high dose of statin treatment on endothelial function and carotid intima-media thickness (IMT) in patients with variant angina (VAP). METHODS: A total of 70 patients with VAP were divided into two groups; atorvastatin 10 mg treatment group (group I: n = 35, 54.2 +/- 12.5 years) versus atorvastatin 40 mg treatment group (group II: n = 35, 52.6 +/- 9.8 years). Flow mediated vasodilation (FMD) of the brachial artery and IMT of the carotid artery were compared between the groups after 6 months of statin treatment. RESULTS: The baseline FMD and carotid IMT were not different between the groups. After 6 months of statin therapy, FMD was significantly improved in both groups (7.7 +/- 2.5% to 8.9 +/- 2.2% in group I, p = 0.001, 7.9 +/- 2.7% to 9.5 +/- 2.8% in group II, p < 0.001), but the degree of FMD change and FMD at 6 month were not different between the groups. Carotid IMT were not changed in both groups after 6 months of statin therapy. CONCLUSION: The use of statin for 6 months significantly improved endothelial function in patients with VAP, but carotid IMT was not changed. The use of high dose statin did not show significant additional benefit as compared with the use of low dose statin. The present study suggested that statin therapy would be beneficial in the treatment of VAP.

Successful Recovery after Cardiac Arrest from Medically Intractable Coronary Spasm Induced by Ergonovine, Using Percutaneous Cardiopulmonary Support: A Case Report / 대한구급학회지

The ergonovine provocation test is often used in diagnosing variant angina. Most patients with an ergonovine-induced coronary artery spasm respond promptly to intracoronary nitroglycerin administration within 3 to 5 minutes. However, in a few patients ergonovine results in serious cardiovascular complications due to intractable coronary artery spasm. We report a case of a severe and medically intractable coronary spasm induced by ergonovine, followed by cardiac arrest. Aided by percutaneous cardiopulmonary support (PCPS) and mechanical ventilation, the patient could survive after four days of hospitalization despite a recurrent vasospasm. Recovery was largely attributed to full supportive care and the use of PCPS.

Variant Angina Associated with Migrating Spontaneous Occlulsive Vasospasm of Right Coronary Artery / 고신대학교의과대학학술지

Variant angina is a syndrome of cyclical chest pain at rest caused by vasospasm and associated with ST-segment elevation. Most of these cases are induced by the provocation with ergonovine or acetylcholine, and mechanical irritation of coronary artery by catheter, but spontaneous migrating spasm in right coronary artery is very rare. We report a fifty one year old male patient presenting as a variant angina due to spontaneous migrating spasm in right coronary artery during diagnostic coronary angiogram. The spasm was relieved spontaneously or by the administration of intracoronary nitroglycerin. No chest pain was documented after medication with calcium-channel blocker and nitrates on 6 month clinical follow-up. This paper presents our experience with a patient presenting with migrating coronay vasospasm of right coronary artery.

Cardiovascular Risk Factors Predicting Endothelial Dysfunction in Patients with Variant Angina / 성인간호학회지

PURPOSE: This study was conducted to identify the clinical characteristics and risk factors on the occurrence of variant angina, and to examine the predicting factors on the vascular endothelial dysfunction of the patients with variant angina. METHODS: A total of 134 patients diagnosed with variant angina were recruited from 2006 to 2008. The degrees of endothelial dysfunction were measured and recorded by the researcher using the values of flow-mediated vasodilation of their brachial arteries and Nitroglycerine-mediated dilation. Subjects' demographic data and risk factors were gathered after obtaining informed consent, and their electronic medical records were reviewed to collect laboratory data. RESULTS: The mean age was 54.2 +/- 9.6 years and 52% was male patients. More than 50% of the male patients were cigarette smokers and had hypercholesterolemia. 84% of the male patients and 70% of the female patients had more than one risk factor of cardiovascular disease. A stepwise multiple regression analysis showed that smoking and hypercholesterolemia predicted the decrease of flow-mediated vasodilation (Adjusted R(2) = .204, p < .001). CONCLUSION: Tailored educational interventions for smoking cessation and cholesterol management are needed to prevent recurrence of angina attack for patients with variant angina and to prevent cardiovascular disease for middle-aged workers.

A case of complete atrioventricular block persisting for 5 days in a patient with variant angina / 대한내과학회지

Variant angina is more common in Asian people, including Koreans. Variant angina has a broad spectrum of clinical manifestations, from intermittent non-exertional pain to syncope and sudden cardiac death. Complete atrioventricular block is a major cause of syncope in patients with variant angina. The complete atrioventricular block related to variant angina is usually transient and easily terminated immediately after the restoration of coronary blood flow. We experienced a case of variant angina combined with prolonged complete atrioventricular block. The complete atrioventricular block persisted after the restoration of coronary blood flow, but normal sinus rhythm was restored spontaneously 5 days later. Here, we report this rare case

Reversible right heart failure and variant angina associated with hyperthyroidism / 대한내과학회지

Thyroid hormone has many effects on the heart and vascular system. Cardiovascular manifestations of excess thyroid hormone are variable, and include enhanced cardiac contractility, enhanced oxygen myocardial consumption, and reduced systemic vascular resistance. Sinus tachycardia, atrial fibrillation, heart failure, and angina pectoris are common clinical manifestations, while right heart failure without severe left heart failure is rare in patients with hyperthyroidism. In addition, ventricular fibrillation may occur in thyrotoxic patients due to myocardial ischemia, such as in variant angina. This case report describes a young woman who presented with right heart failure and variant angina, whose only concurrent illness was hyperthyroidism. The symptoms and sign of right heart failure improved on treating the hyperthyroidism.

Ventricular Tachycardia due to Submucosal Epinephrine Injection during Septoplasty / 대한이비인후과학회지

Local infiltration of dilute solutions of epinephrine is widely used for the purpose of hemostasis during septal surgery. However, infiltrated epinephrine often make several side effects such as palpitation, hypertension, or arrhythmia. Also, it may be possible to experience the catastrophic events such as intracranial hemorrhage, pulmonary edema, and cardiac arrest when we use overdose of epinephrine. We experienced ventricular tachycardia in a 36-year-old male with no significant medical history, after submucosal infiltration of epinephrine with appropriate dose during septoplasty. Intraoperative cardiopulmonary resuscitation by external chest compression and direct current cardioversion was successful. We thoroughly evaluated the patient and proved the diagnosis of variant angina pectoris using coronary angiography.

Reversed Circadian Variation in Variant Angina

It is known that there is a marked variation in the frequency of variant angina attacks according to the circadian rhythm. The attack frequency is usually highest in the early morning and lowest in the afternoon. We describe here a middle-aged woman with variant angina whose chest pain occurred only during daytime. Because of her job, she sleeps from noon to 6 pm, and she experienced chest pain only during 2 to 3 pm. These findings suggest that the alterations to the sleep and wake cycle can affect the circadian variation of variant angina.

A case of congenital bilateral coronary-to-right ventricle fistula coexisting with variant angina

A coronary arteriovenous (AV) fistula consists of a communication between a coronary artery and a cardiac chamber, a great artery or the vena cava. It is the most common anomaly that can affect coronary perfusion. Yet bilateral involvement of a coronary fistula, constitutes an uncommon subgroup of coronary AV fistulas. We herein report on a case of bilateral coronary AV fistula that was coexistent with variant angina originating from the distal right ventricular branch of the right coronary artery and the distal septal branch of the left anterior descending artery, and the latter drained into the right ventricle.