RESUMO
Vasospastic angina (VSA) refers to chest pain experienced as a consequence of myocardial ischaemia caused by epicardial coronary spasm, a sudden narrowing of the vessels responsible for an inadequate supply of blood and oxygen. Coronary artery spasm is a heterogeneous phenomenon that can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction (MI). VSA was originally described as Prinzmetal angina or variant angina, classically presenting at rest, unlike most cases of angina (though in some patients, vasospasm may be triggered by exertion, emotional, mental or physical stress), and associated with transient electrocardiographic changes (transient ST-segment elevation, depression and/or T-wave changes). Ischaemia with non-obstructive coronary arteries (INOCA) is not a benign condition, as patients are at elevated risk of cardiovascular events including acute coronary syndrome, hospitalization due to heart failure, stroke and repeat cardiovascular procedures. INOCA patients also experience impaired quality of life and associated increased healthcare costs. VSA, an endotype of INOCA, is associated with major adverse events, including sudden cardiac death, acute MI and syncope, necessitating the study of the most effective treatment options currently available. The present literature review aims to summarize current data relating to the diagnosis and management of VSA and provide details on the sequence that treatment should follow.
Diagnosis and treatment of epicardial coronary artery spasmVasospastic angina (VSA) refers to chest pain experienced as a consequence of a sudden narrowing of the epicardial coronary arteries. VSA can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction. Reduced blood and oxygen supply in patients with non-obstructive coronary arteries is not a benign condition, as patients are at elevated risk of adverse cardiovascular events. These patients also experience impaired quality of life and associated increased healthcare costs. This review aims to summarise current data relating to the diagnosis of VSA and provides details on treatment strategies.
Assuntos
Angina Pectoris Variante , Doença da Artéria Coronariana , Vasoespasmo Coronário , Infarto do Miocárdio , Humanos , Angina Pectoris Variante/diagnóstico , Angina Pectoris Variante/terapia , Angina Pectoris Variante/complicações , Vasoespasmo Coronário/diagnóstico , Vasoespasmo Coronário/terapia , Vasoespasmo Coronário/complicações , Qualidade de Vida , Angiografia Coronária/efeitos adversos , Dor no Peito/complicações , Espasmo/complicaçõesRESUMO
INTRODUCTION: Since Prinzmetal first described a 'variant' form of angina pectoris, with predominantly resting episodes of pain and cyclic severity variations, it has gradually become apparent that this clinical presentation is caused by episodes of coronary artery spasm (CAS) involving focal or diffuse changes in large and/or small coronary arteries in the presence or absence of 'fixed' coronary artery stenoses. However, most clinicians have only limited understanding of this group of disorders. AREAS COVERED: We examine the clinical presentation of CAS, associated pathologies outside the coronary vasculature, impediments to making the diagnosis, provocative diagnostic tests, available and emerging treatments, and the current understanding of pathogenesis. EXPERT OPINION: CAS is often debilitating and substantially under-diagnosed and occur mainly in women. Many patients presenting with CAS crises have non-diagnostic ECGs and normal serum troponin concentrations, but CAS can be suspected on the basis of history and association with migraine, Raynaud's phenomenon and Kounis syndrome. Definitive diagnosis requires provocative testing at coronary angiography. Treatment still centers around the use of calcium antagonists, but with greater understanding of pathogenesis, new management options are emerging.
Assuntos
Angina Pectoris Variante , Vasoespasmo Coronário , Angina Pectoris/diagnóstico , Angina Pectoris/etiologia , Angina Pectoris Variante/diagnóstico , Angina Pectoris Variante/terapia , Angiografia Coronária , Vasoespasmo Coronário/diagnóstico , Vasoespasmo Coronário/terapia , Vasos Coronários , Feminino , Humanos , EspasmoAssuntos
Angina Pectoris Variante/diagnóstico , Vasoespasmo Coronário/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Anlodipino/administração & dosagem , Angina Pectoris Variante/etiologia , Angina Pectoris Variante/terapia , Cateterismo Cardíaco , Angiografia Coronária , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/terapia , Eletrocardiografia , Feminino , Humanos , Pessoa de Meia-Idade , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapiaAssuntos
Angina Pectoris Variante/diagnóstico , Angina Pectoris Variante/terapia , Aspirina/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Cateterismo Cardíaco , Angiografia Coronária , Quimioterapia Combinada/métodos , Ecocardiografia , Heparina/uso terapêutico , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
No disponible
Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Síndrome da Taquicardia Postural Ortostática/complicações , Angina Pectoris Variante/complicações , Vasodilatadores/uso terapêutico , Síndrome da Taquicardia Postural Ortostática/terapia , Angina Pectoris Variante/terapia , Ecocardiografia/métodos , Angiografia Coronária/métodosRESUMO
A patient with a history of Prinzmetal angina, refractory ventricular fibrillation, cardiac arrest with an implantable cardioverter-defibrillator, and obesity presented to the emergency department at 17 weeks gestational age with a chief complaint of angina and multiple episodes of defibrillation. A T3/4 thoracic epidural was placed to assess the effectiveness of a partial chemical sympathectomy in alleviating symptoms of angina as well as decreasing the amount of defibrillation episodes. Once this proved to be beneficial in accomplishing both of these goals, a more specific approach was designed. A continuous stellate ganglion block was then placed controlling both her angina and preventing further episodes of defibrillation long enough for her pregnancy to progress beyond 24 weeks gestational age.
Assuntos
Angina Pectoris Variante/terapia , Bloqueio Nervoso Autônomo , Fibrilação Ventricular/terapia , Adulto , Feminino , Humanos , Gravidez , Gânglio Estrelado , Adulto JovemRESUMO
Vasospastic angina (VSA) is a variant form of angina pectoris, in which angina occurs at rest, with transient electrocardiogram modifications and preserved exercise capacity. VSA can be involved in many clinical scenarios, such as stable angina, sudden cardiac death, acute coronary syndrome, arrhythmia or syncope. Coronary vasospasm is a heterogeneous phenomenon that can occur in patients with or without coronary atherosclerosis, can be focal or diffuse, and can affect epicardial or microvasculature coronary arteries. This disease remains underdiagnosed, and provocative tests are rarely performed. VSA diagnosis involves three considerations: classical clinical manifestations of VSA; documentation of myocardial ischaemia during spontaneous episodes; and demonstration of coronary artery spasm. The gold standard diagnostic approach uses invasive coronary angiography to directly image coronary spasm using acetylcholine, ergonovine or methylergonovine as the provocative stimulus. Lifestyle changes, avoidance of vasospastic agents and pharmacotherapy, such as calcium channel blockers, nitrates, statins, aspirin, alpha1-adrenergic receptor antagonists, rho-kinase inhibitors or nicorandil, could be proposed to patients with VSA. This review discusses the pathophysiology, clinical spectrum and management of VSA for clinicians, as well as diagnostic criteria and the provocative tests available for use by interventional cardiologists.
Assuntos
Angina Pectoris Variante , Vasos Coronários , Angina Pectoris Variante/diagnóstico por imagem , Angina Pectoris Variante/epidemiologia , Angina Pectoris Variante/fisiopatologia , Angina Pectoris Variante/terapia , Angiografia Coronária , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/efeitos dos fármacos , Vasos Coronários/fisiopatologia , Eletrocardiografia , Medicina Baseada em Evidências , Tolerância ao Exercício , Humanos , Valor Preditivo dos Testes , Prevalência , Prognóstico , Fatores de Risco , Comportamento de Redução do Risco , Vasoconstrição , Vasodilatadores/uso terapêuticoAssuntos
Angina Pectoris Variante/fisiopatologia , Dor no Peito/fisiopatologia , Reestenose Coronária/fisiopatologia , Vasoespasmo Coronário/diagnóstico , Eletrocardiografia , Taquicardia/fisiopatologia , Angina Pectoris Variante/diagnóstico por imagem , Angina Pectoris Variante/terapia , Dor no Peito/diagnóstico por imagem , Dor no Peito/etiologia , Reestenose Coronária/diagnóstico por imagem , Reestenose Coronária/terapia , Vasoespasmo Coronário/diagnóstico por imagem , Vasoespasmo Coronário/fisiopatologia , Vasoespasmo Coronário/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea , Resultado do TratamentoRESUMO
Vasospastic angina, also known as Prinzmetal's angina, is thought to occur due to vascular hyper-reactivity to various stimuli. Response to medical therapy is usually good; however, 1 out of 5 patients has resistant symptoms. Rarely, potentially lethal arrhythmias can occur due to vasospasm, and those patients are reported to have a poorer prognosis. Presently described is a case of resistant vasospastic angina with persistent symptoms under calcium channel blocker and nitrate treatment. The patient presented with hemodynamically unstable rapid-rate ventricular tachycardia, which was quite resistant to recurrent cardioversion. She was treated with stent implantation for definite vasospastic segments of the coronaries, in combination with medical therapy. An implantable cardioverter defibrillator was also implanted for secondary prevention of ventricular arrhythmia, as vasospasm was considered to be a diffuse disease without a certain definitive treatment.
Assuntos
Angina Pectoris Variante/terapia , Vasoespasmo Coronário/terapia , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Stents , Taquicardia/etiologia , Angina Pectoris Variante/complicações , Vasoespasmo Coronário/complicações , Feminino , Humanos , Prevenção Secundária/instrumentação , Taquicardia/prevenção & controle , Taquicardia/terapiaRESUMO
Although coronary obstruction due to atherosclerosis is the most common cause of myocardial ischemia, a significant proportion of patients have myocardial ischemia in the absence of obstructive epicardial coronary artery disease (CAD). This finding is more common among women and alternative causes can mediate myocardial ischemia. Abnormalities in vascular structure, alterations in coronary vasomotion and dysfunction of the coronary microcirculation can all cause ischemia in the absence of obstructive CAD due to atherosclerosis. In this review, we provide an update on three alternative causes of myocardial ischemia: spontaneous coronary artery dissection (SCAD), vasospastic angina (VSA) and coronary microvascular dysfunction (CMVD). We review pathophysiology, clinical presentation, diagnosis, treatment and outcomes related to these important clinical entities. There is increasing interest in better defining this patient population with use of advanced imaging and testing tools. Despite the increased associated risk with future cardiac events, evidence-based treatments for these diagnoses remain under-studied and poorly defined. These alternative diagnoses should be kept in mind when evaluating women with myocardial ischemia without obstructive CAD due to atherosclerosis.
Assuntos
Angina Pectoris Variante/complicações , Circulação Coronária , Anomalias dos Vasos Coronários/complicações , Vasos Coronários/fisiopatologia , Disparidades nos Níveis de Saúde , Microcirculação , Isquemia Miocárdica/etiologia , Doenças Vasculares/congênito , Angina Pectoris Variante/diagnóstico por imagem , Angina Pectoris Variante/fisiopatologia , Angina Pectoris Variante/terapia , Angiografia Coronária , Anomalias dos Vasos Coronários/diagnóstico por imagem , Anomalias dos Vasos Coronários/fisiopatologia , Anomalias dos Vasos Coronários/terapia , Vasos Coronários/diagnóstico por imagem , Eletrocardiografia , Feminino , Humanos , Masculino , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/fisiopatologia , Isquemia Miocárdica/terapia , Valor Preditivo dos Testes , Prognóstico , Fatores de Risco , Fatores Sexuais , Tomografia de Coerência Óptica , Ultrassonografia de Intervenção , Doenças Vasculares/complicações , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/fisiopatologia , Doenças Vasculares/terapiaAssuntos
Angina Pectoris Variante/diagnóstico , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Vasoespasmo Coronário/diagnóstico , Eletrocardiografia Ambulatorial/métodos , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Verapamil/administração & dosagem , Adulto , Angina Pectoris Variante/etiologia , Angina Pectoris Variante/fisiopatologia , Angina Pectoris Variante/terapia , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/tratamento farmacológico , Vasoespasmo Coronário/fisiopatologia , Gerenciamento Clínico , Humanos , Masculino , Resultado do Tratamento , Vasodilatadores/administração & dosagemAssuntos
Angina Pectoris Variante/terapia , Bloqueadores dos Canais de Cálcio/uso terapêutico , Morte Súbita Cardíaca/prevenção & controle , Idoso , Angina Pectoris Variante/complicações , Desfibriladores Implantáveis , Humanos , Masculino , Prevenção Primária , Medição de Risco , Resultado do TratamentoAssuntos
Angina Pectoris Variante/induzido quimicamente , Vasoespasmo Coronário/induzido quimicamente , Desfibriladores Implantáveis , Parada Cardíaca/etiologia , Metilergonovina/efeitos adversos , Idoso , Angina Pectoris Variante/complicações , Angina Pectoris Variante/terapia , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/terapia , Humanos , Masculino , Recidiva , SíncopeAssuntos
Síndrome Coronariana Aguda/patologia , Angina Pectoris Variante/patologia , Angina Instável/patologia , Vasos Coronários/patologia , Músculo Liso Vascular/patologia , Síndrome Coronariana Aguda/terapia , Idoso , Angina Pectoris Variante/terapia , Angina Instável/terapia , Angioscopia , Humanos , Masculino , StentsRESUMO
INTRODUCTION: The adverse effects of synthetic cannabinoids are not well-described nor have they been thoroughly studied. CASE REPORT: A 16-year-old male with a past medical history of asthma and attention deficit hyperactivity disorder (ADHD) presented to the emergency department (ED) complaining of 24 h of substernal pressure associated with dyspnea, nausea, and vomiting. He reported smoking tobacco cigarettes daily and occasional marijuana use but denied recent use of marijuana. The initial electrocardiogram (EKG) revealed ST-segment elevations in leads II, III, AVF, and V4-V6. The initial troponin level was reported as 1.47 ng/mL, and the initial creatine kinase MB (CKMB) level was 17.5 ng/mL. The patient admitted to smoking "K2" 60-90 min prior to the onset of symptoms. The patient manifested persistent ST elevations with a peak troponin of 8.29 ng/mL. The urine drug immunoassay was positive for benzodiazepines and opiates. Cardiac catheterization revealed normal coronary arteries, no wall motion abnormalities, and normal systolic function. DISCUSSION: Synthetic cannabinoids may have significant potential adverse effects. Chest pain due to myocardial ischemia is rare in adolescents. When evaluating patients with chest pain, it is important to elicit a detailed drug history, specifically inquiring about synthetic cannabinoid use. Urine drug immunoassays may be unreliable and in this case did not detect synthetic cannabinoids.
Assuntos
Angina Pectoris Variante/induzido quimicamente , Canabinoides/toxicidade , Drogas Desenhadas/toxicidade , Drogas Ilícitas/toxicidade , Infarto do Miocárdio/induzido quimicamente , Transtornos Relacionados ao Uso de Substâncias/fisiopatologia , Administração por Inalação , Adolescente , Angina Pectoris Variante/diagnóstico , Angina Pectoris Variante/etiologia , Angina Pectoris Variante/terapia , Canabinoides/administração & dosagem , Canabinoides/urina , Dor no Peito/etiologia , Terapia Combinada , Drogas Desenhadas/administração & dosagem , Diagnóstico Diferencial , Eletrocardiografia/efeitos dos fármacos , Reações Falso-Negativas , Humanos , Drogas Ilícitas/urina , Imunoensaio , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/terapia , Autorrelato , Detecção do Abuso de Substâncias , Transtornos Relacionados ao Uso de Substâncias/terapia , Transtornos Relacionados ao Uso de Substâncias/urina , Toxicocinética , Resultado do TratamentoAssuntos
Angina Pectoris Variante/fisiopatologia , Eletrocardiografia , Parada Cardíaca/fisiopatologia , Nitroglicerina/administração & dosagem , Ressuscitação/métodos , Vasodilatadores/administração & dosagem , Adulto , Angina Pectoris Variante/complicações , Angina Pectoris Variante/terapia , Angiografia Coronária , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Humanos , Masculino , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Wearable cardioverter-defibrillators (WCD) have been available in Japan since April 2014, but their application is still limited. METHODSâANDâRESULTS: We report 9 patients with a WCD applied between April and September 2014. All patients were at high risk of life-threatening ventricular arrhythmias. During WCD use, 1 patient had sustained ventricular tachycardia and successful shock delivery; 6 (67%) subsequently underwent implantable cardioverter-defibrillator (ICD) therapy, while 2 had no requirement because of reduced risk, and 1 died of heart failure during WCD use. CONCLUSIONS: WCD is useful during acute-phase care of high-risk patients, and may help to avoid unnecessary ICD implantation.
Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores , Cardioversão Elétrica/métodos , Angina Pectoris Variante/terapia , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/terapia , Miocardite/terapia , Volume Sistólico , Taquicardia Ventricular/tratamento farmacológico , Taquicardia Ventricular/terapia , Resultado do TratamentoRESUMO
Prominent T-wave inversions are well recognized electrocardiographic signs that can occur in acute myocardial infarction (AMI). However, the giant negative T waves may be associated with myocardial stunning without AMI.This case report describes 2 patients without AMI who developed rare giant T-wave inversions measuring up to 35âmm in depth and QT prolongation after admission to hospital. While 1 patient presented with acute pulmonary edema, the other patient presented with severe chest pain at rest and transient ST elevation.The giant T-wave inversion with QT prolongation may be caused by myocardial stunning due to the triple vessel diseases and elevated wall stress, high-end diastolic pressure and decreased coronary arterial flow during pulmonary edema in the first patient. The giant T-wave inversion with QT prolongation in the second patient may be caused by myocardial stunning due to the left anterior descending artery spasm (transient ST elevation) leading to transient total occlusion of left anterior descending artery. Percutaneous coronary intervention was successfully undergone for both patients. The patients remained well.The electrophysiologic mechanism responsible for giant T-wave inversion with QT prolongation is presently unknown. The two cases demonstrate that the rare giant negative T waves may be associated with myocardial stunning without AMI.