scholarly journals Intracoronary acetylcholine testing among 746 consecutive Japanese patients with angina-like chest pain and unobstructed coronary artery disease

2021 ◽  
Author(s):  
Shozo Sueda ◽  
Tomoki Sakaue
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Coronary Arteries ◽  
Myocardial Ischaemia ◽  
Japanese Patients ◽  
Ecg Changes ◽  
Diagnostic Angiography ◽  
Microvascular Spasm ◽  
Artery Disease

Abstract Background Intracoronary acetylcholine (ACh) testing is useful for the detection of epicardial spasm (ES) and coronary microvascular spasm (CMS). Objectives We retrospectively analysed the incidence of ES and CMS in consecutive Japanese patients with unobstructed coronary artery disease. Methods From January 1991 to February 2019, we performed intracoronary ACh testing of 1864 patients. Among these patients, a total of 746 consecutive patients (254 women, mean age 64±11 years) who underwent first diagnostic angiography for suspected myocardial ischaemia and had unobstructed coronary arteries (< 50%) were enrolled. ES was defined as ≥ 90% stenosis and usual chest symptoms and ischaemic ECG changes, while CMS was defined as < 75% stenosis and usual chest symptoms and ischaemic ECG changes. Results We performed intracoronary ACh testing on both coronary arteries in 96% (716/746) of all subjects. Overall, ES was found in 329 patients (44%), whereas CMS was revealed in 40 patients (5%) including 4 patients with coexisting ES. In patients with ES, women made up 22%, and approximately three-quarters of the patients had resting chest pain. In contrast, women composed 65% (26/40) of those with CMS, and 15 patients with CMS had another chest symptom. CMS was frequently observed in the LCA but not the RCA. Electrical cardioversion was necessary for two patients. Conclusions CMS was recognized in only 5% of consecutive Japanese patients with unobstructed coronary artery disease, whereas ES was revealed in 44% of those patients. CMS was often observed in women and in the LCA.

Abstract 129: Chest Pain Characteristics of Myocardial Infarction With Non-Obstructive Coronary Arteries (MINOCA) in Comparison to Myocardial Infarction With Coronary Artery Disease (MI-CAD)

2016 ◽  
Vol 9 (suppl_2) ◽  
Author(s):  
Sivabaskari Pasupathy ◽  
Rosanna Tavella ◽  
Margaret Arstall ◽  
Derek Chew ◽  
Matthew Worthley ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Coronary Arteries ◽  
Public Hospitals ◽  
Arm Pain ◽  
Retrosternal Pain ◽  
Pain Characteristics ◽  
Artery Disease

Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is being increasingly recognized with the frequent use of angiography following Acute Myocardial Infarction (AMI); yet there is little evaluation of these patients in the literature. The current study is a prospective, contemporary analysis of clinical features and chest pain characteristics between patients with MINOCA and Myocardial Infarction with coronary artery disease (MI-CAD). Methods: All consecutive patients undergoing coronary angiography for AMI (as per the Third Universal AMI Definition) in South Australian public hospitals from January 2012 - December 2013 were included. Data was captured by Coronary Angiogram Database of South Australia (CADOSA), a comprehensive registry compatible with the NCDR ® CathPCI ® Registry. The AMI patients were classified as MI-CAD or MINOCA on the basis of the presence or absence of a significant stenosis (≥50%) on angiography. Results: From 3,431 angiography procedures undertaken for AMI, 359 (11%) were classified as MINOCA. MINOCA patients were younger (59 ± 15 vs. 64 ± 13, p <0.01) and more likely to be female (60% vs. 26%, p<0.01), with age adjusted analysis revealing less cardiovascular risk factors in MINOCA compared to MICAD: current smoker (21% vs. 35%, p< 0.01), hypertension (56% vs. 65%, p<0.01), dyslipidaemia (46% vs. 61%, p<0.01), and diabetes (20% vs. 32%, p<0.01). Analysis of presenting chest pain characteristics showed no significant differences between MICAD and MINOCA for the presence of retrosternal pain (81% vs. 82%, p>0.05,) or shoulder pain (27% vs. 26%, p>0.05) respectively, however MINOCA patients were less likely to experience arm pain (33% vs. 40%, p<0.01). In regards to precipitating factors, emotional stress was more common (14% vs. 5%, p<0.001) and exertion related chest pain was less common (27% vs. 40%, p<0.001) in MINOCA patients. Quality of pain for MINOCA and MICAD was similar with the most frequent descriptors being burning (11% vs. 9%, p>0.05), sharp 21% vs. 23%, p>0.05) and tightness (41% vs. 44%, p>0.05). In addition, there were no significant differences observed between groups in relieving factors and duration of chest pain Conclusions: In contemporary cardiology practice, MINOCA presentation is more common than previously appreciated, with younger women frequently implicated. Delineating a MINOCA patient from MICAD on the basis of chest pain characteristics is not feasible.

scholarly journals Proteasome inhibitor-induced coronary vasospasm in multiple myeloma: a case report

2021 ◽  
Vol 5 (7) ◽  
Author(s):  
Philopatir Mikhail ◽  
James Rogers ◽  
Cecily Forsyth ◽  
Thomas J Ford
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Myocardial Ischaemia ◽  
Invasive Coronary Angiography ◽  
Obstructive Coronary Artery Disease ◽  
Coronary Spasm ◽  
Proteasome Inhibition ◽  
Coronary Vasospasm ◽  
Artery Disease

Abstract Background Coronary vasospasm is an increasingly recognized cause of myocardial infarction or myocardial ischaemia in patients without obstructive coronary artery disease. A thorough medication review may identify drugs or toxins that could trigger coronary vasospasm. This case provides mechanistic insight into the off-target effect of proteasome inhibition leading to coronary vasospasm in a patient referred with chest pain consistent with typical angina. Case summary A 72-year-old lady presented with anginal chest pain at rest with electrocardiogram evidence of myocardial ischaemia who was referred for invasive coronary angiography. This demonstrated minor coronary disease without an obstructive lesion. Vasoreactivity testing revealed diffuse coronary vasospasm of the left anterior descending artery. Carfilzomib was identified as the trigger for coronary vasospasm. Symptoms resolved without recurrence after appropriate treatment including cessation of the triggering agent. Conclusion Coronary spasm is a rare but important adverse reaction to proteasome inhibitors. This case supports the clinical utility of invasive coronary vasoreactivity testing in patients with ischaemia with no obstructive coronary artery disease.

Vasospasm induced myocardial ischaemia secondary to sumatriptan use

2020 ◽  
Vol 13 (8) ◽  
pp. e235387 ◽  
Author(s):  
Kenneth Okonkwo ◽  
Utkarsh Ojha
Keyword(s):  
Risk Factors ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Coronary Arteries ◽  
Myocardial Ischaemia ◽  
Myocardial Infarctions ◽  
Acute Migraine ◽  
Artery Disease ◽  
Cluster Headaches ◽  
Prior Risk

Certain medications have been implicated in causing acute myocardial infarctions (AMI). Sumatriptan, a medication usually prescribed for acute migraine and cluster headaches has been documented as potentially causing coronary vasospasm, thereby leading to MI. This is usually seen in patients with strong risk factors for coronary artery disease (CAD) or in those with established CAD. Most cases thus far have been reported in patients using the subcutaneous preparation of sumatriptan. Here, we present a case of a patient without prior risk factors for CAD and angiographically unremarkable coronary arteries who presented with evidence of an AMI after oral sumatriptan use for migraines.

scholarly journals Management of ischaemia with non-obstructive coronary arteries (INOCA)

BMJ ◽  
2021 ◽  
pp. e060602
Author(s):  
John F Beltrame ◽  
Rosanna Tavella ◽  
Dione Jones ◽  
Chris Zeitz
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Coronary Arteries ◽  
Obstructive Coronary Artery Disease ◽  
Personalised Medicine ◽  
Future Research ◽  
Comprehensive Review ◽  
Artery Disease

Abstract Up to half of patients undergoing elective coronary angiography for the investigation of chest pain do not present with evidence of obstructive coronary artery disease. These patients are often discharged with a diagnosis of non-cardiac chest pain, yet many could have an ischaemic basis for their symptoms. This type of ischaemic chest pain in the absence of obstructive coronary artery disease is referred to as INOCA (ischaemia with non-obstructive coronary arteries). This comprehensive review of INOCA management looks at why these patients require treatment, who requires treatment based on diagnostic evaluation, what clinical treatment targets should be considered, how to treat patients using a personalised medicine approach, when to initiate treatment, and where future research is progressing.

scholarly journals EACVI survey on investigations and imaging modalities in chronic coronary syndromes

2020 ◽  
Vol 22 (1) ◽  
pp. 1-7
Author(s):  
Anda Bularga ◽  
Antti Saraste ◽  
Ricardo Fontes-Carvalho ◽  
Espen Holte ◽  
Matteo Cameli ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Medical Therapy ◽  
Myocardial Ischaemia ◽  
Artery Stenosis ◽  
Asymptomatic Patients ◽  
Coronary Syndromes ◽  
Artery Disease ◽  
Test Probability

Abstract Aims The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate current practice for the assessment and management of patients with suspected and confirmed chronic coronary syndromes. Methods and results One-hundred and ten imaging centres from 37 countries across the world responded to the survey. Most non-invasive investigations for coronary artery disease were widely available, except cardiovascular magnetic resonance (available 40% centres). Coronary computed tomography angiography (CCTA) and nuclear scans were reported by a multi-disciplinary team in only a quarter of centres. In the initial assessment of patients presenting with chest pain, only 32% of respondents indicated that they rely on pre-test probability for selecting the optimal imaging test while 31% proceed directly to CCTA. In patients with established coronary artery disease and recurrent chest pain, respondents opted for stress echocardiography (27%) and nuclear stress perfusion scans (26%). In asymptomatic patients with coronary artery disease and an obstructive (&gt;70%) right coronary artery stenosis, 58% of respondents were happy to pursue medical therapy without further testing or intervention. This proportion fell to 29% with left anterior descending artery stenosis and 1% with left main stem obstruction. In asymptomatic patients with evidence of moderate-to-severe myocardial ischaemia (15%), only 18% of respondents would continue medical therapy without further investigation. Conclusion Despite guidelines recommendations pre-test probability is used to assess patients with suspected coronary artery in a minority of centres, one-third of centres moving directly to CCTA. Clinicians remain reticent to pursue a strategy of optimal medical therapy without further investigation or intervention in patients with controlled symptoms but obstructive coronary artery stenoses or myocardial ischaemia.

P4156Coexistence and prognostic impacts of epicardial and microvascular coronary dysfunctions in patients with chest pain and unobstructive coronary artery disease - Involvement of Rho-kinase activation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
A Suda ◽  
J Takahashi ◽  
K Hao ◽  
Y Kikuchi ◽  
T Shindo ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Coronary Arteries ◽  
Coronary Spasm ◽  
Rho Kinase ◽  
Coronary Risk Factors ◽  
Cardiac Events ◽  
Significant Difference ◽  
Artery Disease

Abstract Background Although the importance of coronary functional abnormalities has been emerging, including epicardial coronary spasm (vasospastic angina, VSA) and coronary microvascular dysfunction (CMD), comprehensive evaluation of the abnormalities in the same population remains to be examined. Purpose We examined the significance of coronary functional abnormalities in a comprehensive manner for both epicardial and microvascular coronary arteries in patients with chest pain and unobstructive coronary artery disease (CAD) as well as their prognostic impacts. Methods and results We prospectively enrolled 187 consecutive patients with suspected angina and unobstructive coronary arteries (M/F 113/74, 63.2±12.3 [SD] yrs.). We performed acetylcholine (ACh) provocation tests for coronary spasm, followed by functional tests for coronary microvascular function, including coronary flow reserve (CFR) and index of microcirculation resistance (IMR) during hyperemic state induced by intravenous adenosine. Among the 187 patients, ACh test identified 128 patients with VSA (68%). There was no significant difference in age, sex, or prevalence of traditional coronary risk factors between the non-VSA and the VSA groups. The median IMR value was significantly higher in the VSA group than in the non-VSA group [17.5 (12.0, 25.3) vs. 14.7 (10.7, 17.8), P=0.02], whereas CFR values were comparable between the 2 groups [2.51 (1.72, 3.35) vs. 2.66 (1.85, 3.64), P=0.34]. During the median follow-up period of 893 days, major adverse cardiac events (MACE), including cardiac death, non-fatal myocardial infarction, and hospitalization due to unstable angina pectoris, occurred in 10 patients (5.3%). Multivariable analysis revealed that IMR correlated with the incidence of MACE [hazard ratio (HR) (95% confidence interval), 1.05 (1.02–1.09), P=0.002] and receiver-operating characteristics curve analysis identified IMR of 18.0 as the optimal cut-off value for the incidence of cardiac events. When we divided the patients into the following 4 groups according to the cut-off value of IMR (>18) and the presence or absence of VSA; G1, IMR <18 without VSA (n=45); G2, IMR ≥18 without VSA (n=14); G3, IMR <18 with VSA (n=67); and G4, IMR ≥18 with VSA (n=61), the Kaplan-Meier survival analysis showed a significantly worse prognosis in G4 compared with other 3 groups (HR [95% CI] 6.23 [1.21–118.46], P=0.002) (Figure 1). Importantly, intracoronary administration of fasudil, a Rho-kinase inhibitor, significantly ameliorated IMR in G4 (P<0.0001) (Figure 2A), and %changes in IMR in response to intracoronary fasudil were more evident in G4 compared with other 3 groups (P<0.0001) (Figure 2B). Conclusions These results provide the first evidence that in patients with chest pain and unobstructive CAD, epicardial coronary spasm and increased microvascular resistance are frequently coexisted with worse long-term prognosis, for which Rho-kinase activationmay be involved.

scholarly journals A Possible Etiopathogenic Role of Sickle Cell Anemia in Ischemia With Nonobstructive Coronary Arteries

2020 ◽  
pp. 263246362097758
Author(s):  
Kofi Tekyi Asamoah
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Sickle Cell ◽  
Coronary Arteries ◽  
Sickle Cell Anemia ◽  
Obstructive Coronary Artery Disease ◽  
Exercise Stress ◽  
Microvascular Angina ◽  
Artery Disease

Chest pain is a common clinical symptom, especially in patients with sickle cell anemia. Owing to the vast differential diagnosis, investigation can be challenging. Typical chest pain (angina) is often attributed to obstructive coronary artery disease, with patients being referred for exercise stress tests for confirmation. Microvascular angina is emerging as a cause of significant morbidity worldwide, clinically identical to obstructive coronary artery disease. Clinical assessment and exercise stress testing often give the same results, making differentiation difficult. Coronary angiography however shows either normal coronary arteries or a nonobstructive lesion. An incomplete understanding of the etiopathogenesis of microvascular angina may result in missed diagnosis and suboptimal treatment in some cases. Coronary microvascular dysfunction plays a key role in this phenomenon, driven by chronic inflammation, thrombotic microangiopathy, and endothelial dysfunction. This article reports the case of a young man with chest pain, linking the highlights of the pathophysiology of microvascular disease in sickle cell anemia to microvascular angina.

scholarly journals Role of acetylcholine spasm provocation test as a pathophysiological assessment in nonobstructive coronary artery disease

2020 ◽  
Author(s):  
Satoru Suzuki ◽  
Koichi Kaikita ◽  
Eiichiro Yamamoto ◽  
Hideaki Jinnouchi ◽  
Kenichi Tsujita
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Coronary Arteries ◽  
Coronary Spasm ◽  
Provocation Test ◽  
Left Ventricular ◽  
Coronary Syndrome ◽  
Nonobstructive Coronary Artery Disease ◽  
Microvascular Spasm ◽  
Artery Disease

AbstractCoronary angiography (CAG) sometimes shows nonobstructive coronary arteries in patients with suspected angina or acute coronary syndrome (ACS). The high prevalence of nonobstructive coronary artery disease (CAD) in those patients has recently been reported not only in Japan but also in Western countries, and is clinically attracting attention. Coronary spasm is considered to be one of the leading causes of both suspected stable angina and ACS with nonobstructive coronary arteries. Coronary spasm could also be associated with left ventricular dysfunction leading to heart failure, which could be improved following the administration of calcium channel blockers. Because we rarely capture spontaneous attacks of coronary spasm with electrocardiograms or Holter recordings, an invasive diagnostic modality, acetylcholine (ACh) provocation test, can be useful in detecting coronary spasm during CAG. Furthermore, we can use the ACh-provocation test to identify high-risk patients with coronary spasm complicated with organic coronary stenosis, and then treat with intensive care. Nonobstructive CAD includes not only epicardial coronary spasm but also microvascular spasm or dysfunction that can be associated with recurrent anginal attacks and poor quality of life. ACh-provocation test could also be helpful for the assessment of microvascular spasm or dysfunction. We hope that cardiologists will increasingly perform ACh-provocation test to assess the pathophysiology of nonobstructive CAD.

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