BackgroundThe aim of this study was to elucidate the correlation between angiographic coronary vasomotor responses to intracoronary acetylcholine (ACh) injection, clinical features, and long‐term prognosis in patients with vasospastic angina (VSA).Methods and ResultsThis is a retrospective, observational, single‐center study of 1877 consecutive patients who underwent ACh‐provocation test between January 1991 and December 2010. ACh‐provoked coronary spasm was observed in 873 of 1637 patients included in the present analysis. ACh‐positive patients were more likely to be older male smokers with dyslipidemia, to have a family history of ischemic heart disease, and to have a comorbidity of coronary epicardial stenosis than were ACh‐negative patients. ACh‐positive patients were divided into 2 groups: those with focal (total or subtotal obstruction, n=511) and those with diffuse (severe diffuse vasoconstriction, n=362) spasm patterns. Multivariable logistic regression analysis identified female sex and low comorbidity of coronary epicardial stenosis to correlate with the ACh‐provoked diffuse spasm pattern in patients with VSA. Kaplan–Meier survival curve indicated better 5‐year survival rates free from major adverse cardiovascular events in patients with diffuse spasm pattern compared with those with focal spasm pattern (P=0.019). Multivariable Cox hazard regression analysis identified diffuse spasm pattern as a negative predictor of major adverse cardiovascular events in patients with VSA.ConclusionsACh‐induced diffuse coronary spasm was frequently observed in female VSA patients free of severe coronary epicardial stenosis and was associated with better prognosis than focal spasm. These results suggest the need to identify the ACh‐provoked coronary spasm subtypes in patients with VSA.

BackgroundThe prevalence, clinical features, and long‐term outcome of patients with non–ST‐segment elevation acute coronary syndrome (NSTE ACS) associated with coronary spasm are not fully investigated.Methods and ResultsThis observational multicenter study enrolled 1601 consecutive patients with suspected NSTE‐ACS who underwent cardiac catheterization between January 2001 and December 2010. A culprit lesion was found in 1152 (72%) patients. In patients without a culprit lesion, the acetylcholine provocation test was performed in 221 patients and was positive in 175 patients. In the other patients, coronary spasm was verified in 145 patients during spontaneous attack. Spasm‐induced NSTE‐ACS was diagnosed in 320 (20%) patients. Multivariable analysis identified age <70 years (odds ratio [OR] 2.19, 95% CI 1.58 to 3.04), estimated glomerular filtration rate >60 mL/min per 1.73 m2 (OR 1.72, 95% CI 1.16 to 2.56), and lack of hypertension (OR 2.55, 95% CI 1.90 to 3.41), dyslipidemia (OR 2.76, 95% CI 2.05 to 3.73), diabetes mellitus (OR 2.49, 95% CI 1.78 to 3.48), previous myocardial infarction (OR 5.37, 95% CI 2.89 to 10.0), and elevated cardiac biomarkers (OR 2.84, 95% CI 2.11 to 3.83) as significant correlates of spasm‐induced NSTE‐ACS (P<0.01 for all variables). Transient ST‐segment elevation during spontaneous attack (variant angina) was observed in 119 patients with spasm‐induced NSTE‐ACS. Variant angina was more common in nondyslipidemic men among patients with spasm‐induced NSTE‐ACS.ConclusionsThe study showed frequent involvement of coronary spasm in the pathogenesis of NSTE‐ACS. Variant angina was observed in one third of patients with spasm‐induced NSTE‐ACS. Coronary spasm should be considered even in patients with less coronary risk factors and nonobstructive coronary arteries.

To clarify the determinants of pulmonary valve (PV) motion in pulmonary hypertension, we examined the correlations among PV echo patterns, the pulmonary artery (PA) flow curve just above the PA orifice and the pulmonary artery-right ventricle (PA-RV) pressure gradient. By constricting the PA, we could produce a variety of PV echo patterns, including midsystolic semiclosure in open-chest dogs. Throughout the experiments, the PV echo pattern and PA flow curve were similar in pattern and timing. When the PV echo showed midsystolic semiclosure with reopening. The PA flow curve showed a transient decrease followed by a transient increase during midsystole. The PA-RV pressure gradient became transiently positive (PA pressure greater than RV pressure) and then negative in midsystole only when the PV echo showed midsystolic semiclosure with reopening. In conclusion, PV motion during systole may be instantaneously determined by PA flow change and the PA-RV pressure gradient during the cardiac cycle in experimental pulmonary hypertension.

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Noninvasive pulsed Doppler echocardiography combined with two-dimensional echocardiography by the right parasternal approach was performed to detect the shunt flow through the defect in 31 patients with suspected secundum atrial septal defect (ASD). A defect of the interatrial septum was seen on the two-dimensional echocardiograms of 30 of 31 patients. In all the 30 patients, Doppler signals of shunt flow could be recorded by placing the sample volume in the center of the defect on the two-dimensional echocardiogram. Neither a defect nor Doppler signal indicating shunt flow were demonstrated in any of 15 normal control subjects. Cardiac catheterization indicated significant shunt flow in all the 31 patients with suspected ASD. Doppler signals obtained from the center of the defect showed left-to-right and/or right-to-left shunt flow patterns. The direction of the shunt flow was mainly left to right, with its peak in late systole and atrial systole in 28 of 30 patients; mainly right-to-left flow was present in the remaining two patients, who had Eisenmenger's syndrome. The direction of flow as predicted by the Doppler signal was confirmed by the coincidence of direction of flow as seen on the contrast two-dimensional echocardiogram. In 22 patients for whom the measurement of the pulmonary-to-systemic flow ratio by oximetry was believed to be reasonably accurate, the ratio was fairly well correlated with Doppler-determined left-to-right shunt flow velocity (r = .71, SEE = 6.7 cm/sec). In 13 patients with ASD who underwent surgical repair of the defect, postoperatively the defect on the two-dimensional echocardiogram and the Doppler signals indicating shunt flow disappeared. In conclusion, noninvasive pulsed Doppler echocardiography by the right parasternal approach is useful in the assessment of the direction of shunt flow in patients with ASD.