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1.
Methodist Debakey Cardiovasc J ; 20(1): 26-32, 2024.
Article in English | MEDLINE | ID: mdl-38799179

ABSTRACT

We present the case of a 60-year-old male, with active smoking and cocaine use disorder, who reported progressive chest pain. Various anatomical and functional cardiac imaging, performed to further evaluate chest pain etiology, revealed changing severity and distribution of left main artery (LMA) stenosis, raising suspicion for vasospasm. Intracoronary nitroglycerin relieved the vasospasm, with resolution of the LMA pseudostenosis. A diagnosis of vasospastic angina (VA) led to starting appropriate medical therapy with lifestyle modification counselling. This case highlights VA, a frequently underdiagnosed etiology of angina pectoris. We discuss when to suspect VA, its appropriate work-up, and management.


Subject(s)
Coronary Angiography , Coronary Stenosis , Coronary Vasospasm , Nitroglycerin , Vasodilator Agents , Humans , Male , Middle Aged , Coronary Stenosis/diagnostic imaging , Coronary Stenosis/therapy , Coronary Stenosis/physiopathology , Coronary Vasospasm/diagnostic imaging , Coronary Vasospasm/physiopathology , Coronary Vasospasm/drug therapy , Coronary Vasospasm/therapy , Coronary Vasospasm/diagnosis , Nitroglycerin/administration & dosage , Treatment Outcome , Vasodilator Agents/therapeutic use , Vasodilator Agents/administration & dosage , Predictive Value of Tests , Cocaine-Related Disorders/complications , Severity of Illness Index , Angina Pectoris/etiology , Angina Pectoris/diagnostic imaging , Diagnosis, Differential , Smoking/adverse effects
2.
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
3.
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
5.
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
8.
Arch Cardiovasc Dis ; 116(12): 590-596, 2023 Dec.
Article in English | MEDLINE | ID: mdl-37891058

ABSTRACT

Vasospastic angina, also described as Prinzmetal angina, was first described as a variant form of angina at rest with transient ST-segment elevation; it is common and present in many clinical scenarios, including chronic and acute coronary syndromes, sudden cardiac death, arrhythmia and syncope. However, vasospastic angina remains underdiagnosed, and provocative tests are rarely performed. The gold-standard diagnostic approach uses invasive coronary angiography to induce coronary spasm using ergonovine, methylergonovine or acetylcholine as provocative stimuli. The lack of uniform protocol decreases the use and performance of these tests, accounting for vasospastic angina underestimation. This position paper from the French Coronary Atheroma and Interventional Cardiology Group (GACI) aims to review the indications for provocative tests, the testing conditions, drug protocols and positivity criteria.


Subject(s)
Angina Pectoris, Variant , Cardiology , Coronary Artery Disease , Coronary Vasospasm , Plaque, Atherosclerotic , Humans , Coronary Angiography , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/therapy , Coronary Vasospasm/diagnosis , Coronary Vasospasm/diagnostic imaging , Spasm
10.
Pacing Clin Electrophysiol ; 46(8): 868-874, 2023 08.
Article in English | MEDLINE | ID: mdl-37461879

ABSTRACT

BACKGROUND: J-waves may be observed during coronary angiography (CAG) or intracoronary acetylcholine (ACh) administration, but their significance is unknown. METHODS: Forty-nine patients, 59.1 ± 11.5 years old and 59% male, were studied on suspicion of vasospastic angina, and J wave dynamicity was compared between CAG and Ach administration. RESULTS: Diagnostic (≥0.1 mV) or nondiagnostic (<0.1 mV) J waves in 9 and 3 patients, respectively, were augmented, and J waves were newly observed in 2 patients during CAG and Ach administration. Similar changes in the J-wave amplitude were observed: from 0.10 ± 0.09 mV to 0.20 ± 0.15 mV (p < .002) and from 0.10 ± 0.10 mV to 0.20 ± 0.16 mV (p < .001) during CAG and Ach administration, respectively. J waves were located in the inferior leads and changed only during the right coronary interventions. In the remaining 35 patients, J waves were absent before and during the coronary interventions. Augmentation of J waves was found when the RR interval was shortened in some patients. Injection of anoxic media into the coronary artery might induce a conduction delay from myocardial ischemia that manifests as augmentation or new occurrence of J waves. CONCLUSIONS: Both CAG and intracoronary Ach administration affected J waves similarly in the same individuals. A myocardial ischemia-induced conduction delay may be responsible for the changes in J waves, but further studies are needed.


Subject(s)
Coronary Artery Disease , Coronary Vasospasm , Myocardial Ischemia , Humans , Male , Middle Aged , Aged , Female , Acetylcholine/adverse effects , Coronary Angiography , Arrhythmias, Cardiac , Coronary Vessels/diagnostic imaging , Coronary Vasospasm/diagnostic imaging , Coronary Vasospasm/chemically induced
11.
J Cardiol ; 82(6): 455-459, 2023 12.
Article in English | MEDLINE | ID: mdl-37459964

ABSTRACT

BACKGROUND: n-3 polyunsaturated fatty acids (PUFAs) reduce the risk of ischemic heart disease. However, there are few reports of a relationship between n-3 PUFAs and coronary spastic angina (CSA). This study aimed to assess the age-dependent role of serum levels of fatty acid in patients with CSA. METHODS AND RESULTS: We enrolled 406 patients who underwent ergonovine tolerance test (ETT) during coronary angiography for evaluation of CSA. All ETT-positive subjects were diagnosed as having CSA. We categorized the patients by age and results of ETT as follows: (1) young (age ≤ 65 years) CSA-positive (n = 32), (2) young CSA-negative (n = 134), (3) elderly (age > 66 years) CSA-positive (n = 36), and (4) elderly CSA-negative (n = 204) groups. We evaluated the serum levels of eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), arachidonic acid, and dihomo-gamma-linolenic acid. In the young groups, the serum levels of EPA (64.3 ±â€¯37.7 µg/mL vs. 49.4 ±â€¯28.8 µg/mL, p = 0.015) and DHA (135.7 ±â€¯47.6 µg/mL vs. 117.4 ±â€¯37.6 µg/mL, p = 0.020) were significantly higher in the CSA-positive group than in the CSA-negative group, respectively. However, this was not the case with elderly groups. In the multivariate analysis in young groups, the serum levels of EPA (p = 0.028) and DHA (p = 0.049) were independently associated with the presence of CSA, respectively. CONCLUSION: Our results suggested that the higher serum levels of EPA and/or DHA might be involved in the pathophysiology of CSA in the young population but not in the elderly population.


Subject(s)
Angina Pectoris , Coronary Vasospasm , East Asian People , Fatty Acids, Unsaturated , Aged , Humans , Docosahexaenoic Acids/blood , Eicosapentaenoic Acid/blood , Fatty Acids , Fatty Acids, Omega-3/blood , Fatty Acids, Unsaturated/blood , Angina Pectoris/etiology , Coronary Vasospasm/blood , Coronary Vasospasm/chemically induced , Coronary Vasospasm/diagnostic imaging , Age Factors , Ergonovine/adverse effects , Vasoconstrictor Agents/adverse effects , Coronary Angiography , Middle Aged
12.
Intern Med ; 62(24): 3643-3647, 2023 Dec 15.
Article in English | MEDLINE | ID: mdl-37164672

ABSTRACT

A 46-year-old man presented to our hospital with chest pain followed by coughing and dyspnea. His myocardial enzyme levels were almost normal, and electrocardiography and echocardiography showed no obvious abnormalities. Chest radiography revealed congestion. He was diagnosed with heart failure with a preserved ejection fraction (HFpEF). Although subjective symptoms improved with intravenous diuretics, the patient was admitted to the hospital for a close examination. Coronary angiography showed no obvious stenosis, and a subsequent spasm provocation test demonstrated the presence of multi-vessel and diffuse spasms. Coronary spasm should be considered as a differential cause of heart failure, even in patients with HFpEF.


Subject(s)
Coronary Vasospasm , Heart Failure , Male , Humans , Middle Aged , Heart Failure/etiology , Heart Failure/diagnosis , Stroke Volume , Heart , Coronary Vasospasm/diagnosis , Coronary Vasospasm/diagnostic imaging , Coronary Angiography , Spasm
13.
BMC Cardiovasc Disord ; 23(1): 199, 2023 04 17.
Article in English | MEDLINE | ID: mdl-37069508

ABSTRACT

BACKGROUND: Methylergonovine is a vasoconstrictive agent historically used as a provocative agent in the lab for coronary vasospasm; it is also a first line uterotonic agent for management of postpartum hemorrhage. CASE PRESENTATION: A 29-year-old female with history of smoking and idiopathic thrombocytopenia received intramuscular methylergonovine after delivery of twins for intrauterine hemorrhage management. Subsequently, she had episodes of chest pain with high sensitivity Troponin I elevation to 1509 ng/L with accompanying septal T wave inversions, decreased left ventricular ejection fraction to 49% and basal septal wall hypokinesis. Computed tomography (CT) coronary angiogram showed patent coronary arteries and no coronary arterial dissection. The patient was conservatively managed with aspirin and metoprolol, and on follow up had fully recovered left ventricular function with resolution of wall motion abnormalities. Given this, coronary vasospasm due to intramuscular methylergonovine is the most likely cause of patient's chest pain and associated myocardial ischemia. CONCLUSIONS: Intramuscular, intrauterine, intravenous, and even oral methylergonovine can rarely cause coronary vasospasm leading to myocardial ischemia. Cardiologists caring for postpartum patients should be aware of these potential lethal complications; prompt identification and administration of sublingual nitroglycerin can prevent severe complications of arrythmias, heart block, or cardiac arrest.


Subject(s)
Coronary Artery Disease , Coronary Vasospasm , Methylergonovine , Myocardial Ischemia , Pregnancy , Female , Humans , Adult , Coronary Vasospasm/chemically induced , Coronary Vasospasm/diagnostic imaging , Coronary Vasospasm/drug therapy , Methylergonovine/adverse effects , Stroke Volume , Ventricular Function, Left , Myocardial Ischemia/complications , Coronary Artery Disease/complications , Chest Pain , Postpartum Period
15.
BMJ Case Rep ; 16(2)2023 Feb 10.
Article in English | MEDLINE | ID: mdl-36764737

ABSTRACT

A man in his 40s who was previously well had an out-of-hospital cardiac arrest. Postresuscitation ECG showed ST-elevation myocardial infarction (MI). Emergency coronary angiogram revealed MI with non-obstructive coronary arteries (MINOCA) with evidence of spasm in the right coronary artery. Both his echocardiogram and cardiac MRI revealed a normal heart. Further workup showed markedly elevated free T4 (99.5 pmol/L) and free T3 (26.7 pmol/L) with low thyroid stimulating hormone (<0.02 pmol/L) in keeping with thyroid storm. He also had an elevated adjusted calcium level (2.84 mmol/L), which could have contributed to his coronary artery spasm. His peak troponin T was elevated at 798 ng/L (<14) suggesting myocardial damage. He was treated with propylthiouracil, steroids, beta-blocker, calcium channel blocker and intravenous fluids. The patient achieved a full recovery and was discharged home. This is an unusual case of thyroid dysfunction resulting in coronary artery spasm, cardiac arrest and MINOCA.


Subject(s)
Coronary Vasospasm , Heart Arrest , Male , Humans , Coronary Vasospasm/complications , Coronary Vasospasm/diagnostic imaging , MINOCA , Coronary Vessels/diagnostic imaging , Coronary Angiography , Heart Arrest/complications
16.
Ann Noninvasive Electrocardiol ; 28(3): e13037, 2023 05.
Article in English | MEDLINE | ID: mdl-36625433

ABSTRACT

Coronary artery spasm (CAS) can cause unstable angina, and the treatment of this disease is controversial. We report an elderly male patient who was admitted to hospital due to chest tightness. CAG showed that 70% stenosis in the middle of the right coronary artery (RCA). A bioresorbable scaffold (BRS) was implanted in the lesion under the guidance of optical coherence tomography (OCT). One year later, the patient's symptoms were relieved. The repeated CAG showed that the stent was good. BRS implantation under the guidance of treadmill test and OCT is one of treatment options for CAS patients.


Subject(s)
Coronary Artery Disease , Coronary Vasospasm , Percutaneous Coronary Intervention , Humans , Male , Aged , Absorbable Implants , Coronary Vasospasm/diagnostic imaging , Coronary Vasospasm/surgery , Coronary Angiography , Tomography, Optical Coherence/methods , Exercise Test , Treatment Outcome , Electrocardiography , Percutaneous Coronary Intervention/methods , Coronary Vessels/diagnostic imaging , Coronary Vessels/surgery , Coronary Artery Disease/diagnosis
20.
Korean J Anesthesiol ; 76(1): 72-76, 2023 02.
Article in English | MEDLINE | ID: mdl-35978452

ABSTRACT

BACKGROUND: Sugammadex is a widely used medication for the reversal of aminosteroid neuromuscular blockades. Although sugammadex is generally regarded to be safe, concerns about the risk of serious complications have emerged. CASE: A 57-year-old man without a history of coronary disease was scheduled for general anesthesia to undergo cardiac radiofrequency catheter ablation due to symptomatic persistent atrial fibrillation and flutter. At the end of the procedure, he was given 400 mg of sugammadex. A little later, the electrocardiogram showed a sudden ST elevation on the inferior leads, followed by cardiac arrest. The urgent coronary angiography demonstrated total collapse of the right coronary artery. After two injections of intra-coronary nitroglycerin, the vasospasm of the right coronary artery was completely resolved. The patient recovered without sequelae and was discharged on postoperative day 5. CONCLUSIONS: Clinicians should pay close attention to the potential risk of coronary vasospasm, even cardiac arrest, after sugammadex administration.


Subject(s)
Coronary Vasospasm , Heart Arrest , Male , Humans , Middle Aged , Coronary Vasospasm/chemically induced , Coronary Vasospasm/diagnostic imaging , Coronary Vasospasm/complications , Sugammadex/adverse effects , Heart Arrest/chemically induced , Coronary Angiography/adverse effects
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