Coronary artery spasm and microvascular angina

2019 ◽  
pp. 107-122
Author(s):  
Peter Ong ◽  
Udo Sechtem
Keyword(s):  
Coronary Artery ◽  
Coronary Artery Spasm ◽  
Coronary Spasm ◽  
Pharmacological Therapy ◽  
Coronary Microvascular Dysfunction ◽  
Channel Blockers ◽  
Pharmacological Management ◽  
Microvascular Angina ◽  
Drug Classes ◽  
Coronary Abnormalities

Ischaemic heart disease comprises a variety of coronary abnormalities, ranging from obstructive atherosclerotic stenoses to functional coronary vasomotor disorders. The latter comprise coronary spasm, as well as coronary microvascular dysfunction. Importantly, structural and functional abnormalities can coexist in a given patient, making it sometimes difficult to determine the underlying cause of angina. Thus, diagnostic algorithms should not only consider the evaluation of atherosclerotic epicardial disease, but also look for the presence of functional coronary disorders. This holds especially true for patients in whom obstructive coronary disease has been excluded, as many of these patients are labelled as having ‘non-cardiac chest pain’. Such an approach may enable the treating physician to adjust the pharmacological therapy more appropriately, in order to improve symptoms and prognosis. Often drug classes such as calcium channel blockers and nitrates are beneficial in these patients. This chapter gives an overview on the current pharmacological management of patients with coronary artery spasm and those suffering from microvascular angina.

Coronary artery spasm and microvascular angina

2019 ◽  
pp. 107-122
Author(s):  
Peter Ong ◽  
Udo Sechtem
Keyword(s):  
Coronary Artery ◽  
Coronary Artery Spasm ◽  
Coronary Spasm ◽  
Pharmacological Therapy ◽  
Coronary Microvascular Dysfunction ◽  
Channel Blockers ◽  
Pharmacological Management ◽  
Microvascular Angina ◽  
Drug Classes ◽  
Coronary Abnormalities

Ischaemic heart disease comprises a variety of coronary abnormalities, ranging from obstructive atherosclerotic stenoses to functional coronary vasomotor disorders. The latter comprise coronary spasm, as well as coronary microvascular dysfunction. Importantly, structural and functional abnormalities can coexist in a given patient, making it sometimes difficult to determine the underlying cause of angina. Thus, diagnostic algorithms should not only consider the evaluation of atherosclerotic epicardial disease, but also look for the presence of functional coronary disorders. This holds especially true for patients in whom obstructive coronary disease has been excluded, as many of these patients are labelled as having ‘non-cardiac chest pain’. Such an approach may enable the treating physician to adjust the pharmacological therapy more appropriately, in order to improve symptoms and prognosis. Often drug classes such as calcium channel blockers and nitrates are beneficial in these patients. This chapter gives an overview on the current pharmacological management of patients with coronary artery spasm and those suffering from microvascular angina.

Abstract 14849: Gender Differences in Impact of CYP2C19 Polymorphism and Low Grade Inflammation on Coronary Spasm in Patients with Vasospastic Angina (VSA)

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Tomonori Akasaka ◽  
Seiji Hokimoto ◽  
Noriaki Tabata ◽  
Kenji Sakamoto ◽  
Kenichi Tsujita ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Coronary Artery Spasm ◽  
Coronary Spasm ◽  
Control Group ◽  
Low Grade ◽  
Cyp2c19 Genotype ◽  
Loss Of Function ◽  
Hs Crp ◽  
The Impact ◽  
Low Grade Inflammation

Background: Several cytochrome P450 (CYP) enzyme families have been identified in extra hepatic tissues such as heart, vasculature, kidney, and lung. CYP2C19 localized in vascular smooth muscle and endothelium contributes to the regulation of vascular tone and homeostasis. However, it is unknown whether CYP2C19 genotype is associated with the vascular tonus in patients with VSA. The aim of this study was to examine the impact of CYP2C19 genotype on coronary artery spasm in patients with VSA. Methods: We examined the distribution of CYP2C19 genotype in patients with VSA (n=129) who were diagnosed by intra-coronary acetylcholine infusion test and healthy subjects (n=455) as control group. CYP2C19 genotypes were divided into 3 groups; (1) CYP2C19*1/*1: EM, (2) one loss-of-function allele (*1/*2, *1/*3: IM), and (3) two loss-of-function alleles (*2/*2, *2/*3, *3/*3: PM). Moreover, we measured the level of high-sensitive CRP (hs-CRP) as a degree of low glade inflammation in each group. Results: The ratios of CYP2C19 genotype (EM, IM, and PM) were 30, 42, and 28% in VSA group, and 32, 49, and 19% in control group. In short, PM frequency was significantly higher in VSA than in control (28% vs 19%, P=0.026). In VSA group, the ratios of CYP2C19 genotype were 36, 44, and 20% in male, and 20, 39, and 41% in female, respectively. Briefly, the PM frequency was significantly higher in female than in male (41% vs 20%, P<0.001). Moreover, the level of hs-CRP was significantly higher in VSA group than in control group (0.17±0.367 vs 0.10.±0.240, P=0.02). When patients were stratified by gender, the level of hs-CRP was significantly higher in VSA group in female (0.11±0.198 vs 0.06±0.105, P=0.031) and male (0.20±0.438 vs 0.12±0.277, P=0.044). Multivariate analysis for coronary spasm indicated high age, hypertension, and high level of hs-CRP as predictive factors among all subjects. PM is a predictive factor for coronary spasm in female group only (OR3.1, 95%RI 1.525-6.317, P=0.002), but not in male (OR0.829, 95%RI 0.453-1.518, P=0.543). Conclusion: The CYP2C19 two loss-of-function alleles (PM) and low grade inflammation may be associated with pathophysiology of coronary artery spasm and the regulation of coronary tonus, especially in female.

scholarly journals COVID-19 Pneumonia with Atrial Fibrillation, Coronary Spasm, and Wavy Triple Sign (Yasser’s Sign); Dramatic Reversal at Home Management

2021 ◽  
pp. 20-23
Author(s):  
Yasser Mohammed Hassanain Elsayed
Keyword(s):  
Atrial Fibrillation ◽  
Coronary Artery ◽  
Coronary Artery Spasm ◽  
Coronary Spasm ◽  
Initial Therapy ◽  
Good Prognosis ◽  
Elderly Male ◽  
St Segment

Rationale: A novel COVID-19 with a severe acute respiratory syndrome or pneumonia had arisen in Wuhan, China in December 2019. Emerging atrial fibrillation in COVID-19 patients is highly significant in cardiovascular medicine. A newly coronary artery spasm in the presentation of COVID-19 infection has certainly a risk impact on both morbidity and mortality of COVID-19 patients. Wavy triple an electrocardiographic sign (Yasser Sign) is an innovated sign of hypocalcaemia linked to tachypnea and acute respiratory distress. Patient concerns: An elderly male COVID-19 patient presented to physician outpatient clinic with bilateral pneumonia, atrial fibrillation, evidence of coronary artery spasm, and Wavy triple an electrocardiographic sign (Yasser Sign). Diagnosis: COVID-19 pneumonia with coronary artery spasm and the Wavy triple an electrocardiographic sign (Yasser Sign). Interventions: Chest CT scan, electrocardiography, oxygenation, and echocardiography. Outcomes: Gradual dramatic clinical, electrocardiographic, and radiological improvement had happened. Lessons: The reversal of electrocardiographic ST-segment depressions in a COVID-19 patient after adding oral nitroglycerine is an indicator for the presence of coronary artery spasm. It signifies the role of the anti-infective drugs, anticoagulants, antiplatelet, and steroids in COVID-19 patients with bilateral pneumonia, AF, coronary artery spasm are effective therapies. The disappearance of AF after initial therapy may a guide for a good prognosis in this case study. The evanescence of Wavy triple ECG sign as a hallmark for the existence of the Movable-weaning phenomenon of hypocalcaemia is recommended for further wide-study.

Vasospastic angina

ESC CardioMed ◽  
2018 ◽  
pp. 1427-1430
Author(s):  
Peter Ong ◽  
Udo Sechtem
Keyword(s):  
Kinase Inhibitors ◽  
Coronary Revascularization ◽  
Coronary Spasm ◽  
Underlying Mechanism ◽  
Vasospastic Angina ◽  
Coronary Microvascular Dysfunction ◽  
Channel Blockers ◽  
Short Acting ◽  
St Segment Elevation ◽  
Provocation Testing

The hallmark of vasospastic angina is angina at rest that promptly responds to short-acting nitrates. Classically, there is a preserved exercise capacity and the underlying mechanism is a focal occlusive spasm of the epicardial arteries with transient ST-segment elevation on the electrocardiogram (i.e. Prinzmetal’s, or variant angina). However, the clinical presentation of epicardial spasm may also comprise exercise-related symptoms. Intracoronary provocation testing with acetylcholine is the method of choice to establish the diagnosis and this can be performed with a good safety profile. Coronary spasm may occur in patients with normal or unobstructed coronary arteries but also in patients with epicardial stenoses and those with previous coronary revascularization. Distribution of epicardial spasm can be focal or diffuse and involve multiple locations. In European patients, diffuse spasm of the distal left anterior descending coronary artery is a frequent finding. Coronary spasm may also exist at the level of the coronary microcirculation which represents a form of coronary microvascular dysfunction. Despite good efficacy of calcium channel blockers and short-acting nitrates, a substantial number of patients have refractory symptoms. Apart from optimal risk factor control, emerging drugs for these patients include, for example, rho kinase inhibitors.

scholarly journals Coronary Microvascular Dysfunction: An Update

2020 ◽  
Vol 16 (1) ◽  
pp. 43-49
Author(s):  
Sm Mustafa Zaman ◽  
Harisul Hoque ◽  
Khurshed Ahmed ◽  
Md Mukhlesur Rahman ◽  
Msi Tipu Chowdhury ◽  
...  
Keyword(s):  
Magnetic Resonance ◽  
Myocardial Perfusion ◽  
Current Knowledge ◽  
Systolic Dysfunction ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Resonance Spectroscopy ◽  
Channel Blockers ◽  
Converting Enzyme Inhibitors ◽  
Microvascular Angina

Structural and functional abnormalities of the microcirculation can impair myocardial perfusion which is called coronary microvascular dysfunction and the resulting ischemia is known as microvascular ischaemia. Most of the researches have focused on the epicardial coronary arteries while addressing angina pectoris. Although the importance of the coronary microcirculation in maintaining appropriate myocardial perfusion has been recognized for several decades, the substantial morbidity of coronary microvascular dysfunction (CMD) has not been appreciated until recently. It is not possible to diagnose of microvascular angina clinically with the current knowledge. Resting or exercise electrocardiogram is nondiagnostic. Imaging with speckle tracking in echocardiography may reveal focal diastolic and/or systolic dysfunction. Other noninvasive investigations includes, Contrast stress echocardiography, 99Tc-sestamibi imaging, cardiovascular magnetic resonance (CMR),Nuclear magnetic resonance spectroscopy may show some degree of abnormality. Invasive methods like intracoronary adenosine and acetylecholine test may guide us to diagnose CMD. No guideline directed medical therapy is still available for the CMD. Risk factors modification like smoking cessation and weight-loss may improve endothelial dysfunction and CMD. Beta blockers, calcium channel blockers, Angiotensin converting enzyme inhibitors and statin are now used in different clinical condition related to microvascular angina. After these medical treatment patient with microvascular angina have higher risk of MACE compared with people without angina. So, physicians must be aware of this potentially fatal but under recognized clinical entity. University Heart Journal Vol. 16, No. 1, Jan 2020; 43-49

Chain pain following cardiac surgery in a 35-year-old man

Heart ◽  
2018 ◽  
Vol 105 (3) ◽  
pp. 234-243 ◽  
Author(s):  
Benjamin Marchandot ◽  
Bogdan Radulescu ◽  
Olivier Morel
Keyword(s):  
Coronary Artery ◽  
Coronary Angiography ◽  
Coronary Artery Spasm ◽  
Mechanical Valve ◽  
Supplementary File ◽  
List Type ◽  
Left Main ◽  
Severe Aortic Regurgitation ◽  
Coronary Syndrome ◽  
Coronary Abnormalities

Clinical introductionA 35-year-old man with multiple cardiovascular risk factors presented with a recent history of fever and acute heart failure. His initial echocardiogram showed evidence of severe aortic regurgitation due to ongoing infective endocarditis. Preoperative coronary angiography revealed no coronary abnormalities. Urgent aortic valve replacement was performed and a 29 mm St Jude mechanical valve was implanted. While blood and resected valvular tissue cultures were negative for bacteria, a PCR-based analysis revealed the presence of penicillin-sensitive Streptococcus pneumoniae. Echocardiographic follow-up study at day 3 showed excellent mechanical valve function with no persistent signs of endocarditis. Eight days after surgery, our patient presented with severe chest pain. The ECG is shown in figure 1A and coronary angiography was performed for diagnostic confirmation (figure 1B–D and online supplementary video 1).Supplementary file 1Figure 1(A) 12-lead ECG. (B, C) Selective angiogram of the left main, left anterior descending artery and circumflex artery. (D) Aortic root angiography.QuestionWhich of the following is most likely the diagnostic?Occlusion of the left anterior descending coronary arteryDissection of the left anterior descending coronary arteryValsalva aneurysm presenting as an acute coronary syndromeLeft anterior descending coronary artery spasmLeft main coronary aneurysm

The coronary microcirculation and coronary microvascular dysfunction

2021 ◽  
pp. 18-21
Author(s):  
Romana Herscovici ◽  
C. Noel Bairey Merz
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Obstructive Coronary Artery Disease ◽  
Signs And Symptoms ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Microvascular Angina ◽  
Cardiac Syndrome ◽  
Artery Disease

The role of revascularization in the treatment of obstructive coronary artery disease is well established, and its impact on improving survival has been proven. Nevertheless, patients with signs and symptoms considered of cardiac origin but with no obstructive coronary artery disease on coronary angiography are increasingly seen. Initially described as a ‘paradox’ or cardiac syndrome X and subsequently defined as microvascular angina, angina-like chest pain and evidence of ischaemia with non-obstructive coronary artery disease, is the consequence of altered coronary microvascular response to various stimuli despite non-obstructed epicardial vessels.

Myocardial ischaemia: definition and causes

ESC CardioMed ◽  
2018 ◽  
pp. 1325-1329
Author(s):  
Filippo Crea ◽  
Gaetano Antonio Lanza
Keyword(s):  
Coronary Artery ◽  
Myocardial Ischaemia ◽  
Coronary Artery Spasm ◽  
Chronic Stable Angina ◽  
Oxygen Demand ◽  
Microvascular Dysfunction ◽  
Myocardial Oxygen Demand ◽  
Coronary Microvascular Dysfunction ◽  
Coronary Artery Dissection ◽  
The Right

Myocardial ischaemia is caused by a mismatch between myocardial oxygen demand and myocardial blood flow supply, which results in reversible myocardial suffering and, when prolonged, in irreversible injury. The main causes of myocardial ischaemia include (1) atherosclerotic flow-limiting stenoses which are responsible for chronic stable angina; (2) coronary thrombus superimposed on an atherosclerotic plaque which is responsible for acute coronary syndromes; (3) coronary artery spasm which is responsible for vasospastic angina; and (4) coronary microvascular dysfunction which is responsible for microvascular angina and can also contribute to myocardial ischaemia in various clinical settings. Functional alterations (thrombus, spasm, and microvascular dysfunction) may act on angiographically normal coronary arteries or arteries presenting stenoses of variable severity. Less frequent coronary causes of myocardial ischaemia include spontaneous coronary artery dissection, myocardial bridge, coronary thromboembolism, an abnormal origin of the right or left coronary artery, and ascending aorta dissection involving coronary ostia. Finally, myocardial ischaemia can occur in the presence of severe left ventricular hypertrophy as observed in aortic stenosis and hypertrophic cardiomyopathy.

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