Coronary Artery Spasm: New Insights

Abstract

Coronary artery spasm (CAS) defined by a severe reversible diffuse or focal vasoconstriction is the most common diagnosis among INOCA (ischemia with no obstructive coronary artery disease) patients irrespective to racial, genetic, and geographic variations. However, the prevalence of CAS tends to decrease in correlation with the increasing use of medicines such as calcium channel blockers, angiotensin converting enzyme inhibitor, and statins, the controlling management of atherosclerotic risk factors, and the decreased habitude to perform a functional reactivity test in highly active cardiac catheterization centers. A wide spectrum of clinical manifestations from silent disease to sudden cardiac death was attributed to this complex entity with unclear pathophysiology. Multiple mechanisms such as the autonomic nervous system, endothelial dysfunction, chronic inflammation, oxidative stress, and smooth muscle hypercontractility are involved. Regardless of the limited benefits proffered by the newly emerged cardiac imaging modalities, the provocative test remains the cornerstone diagnostic tool for CAS. It allows to reproduce CAS and to evaluate reactivity to nitrates. Different invasive and noninvasive therapeutic approaches are approved for the management of CAS. Long-acting nondihydropyridine calcium channel blockers are recommended for first line therapy. Invasive strategies such as PCI (percutaneous coronary intervention) and CABG (coronary artery bypass graft) have shown benefits in CAS with significant atherosclerotic lesions. Combination therapies are proposed for refractory cases.

Coronary Artery Spasm During Catheter Ablation Caused by the Intravenous Infusion of Isoproterenol

“…A through a preoperative history should be taken to determine whether a patient has a risk of CAS. The main risk factors for CAS are age, a smoking history, Japanese ethnicity, hypertension, and diabetes mellitus, and it can be precipitated by various factors such as mental exercise, cold exposure, hyperventilation, or alcohol consumption ( 16 ). Although this patient was Caucasian and did not have alcohol flushing syndrome, the present case had history of nicotine dependence and alcohol abuse.…”

COVID‐19 and Acute Coronary Syndromes: From Pathophysiology to Clinical Perspectives

“…Several mechanisms have been proposed for these cases, including plaque erosion, microthrombi, or coronary vasospasm [ 41 , 98 , 99 ]. The pathophysiology seems to be multifactorial and encompasses inflammatory activation, oxidative stress, and endothelial dysfunction in the context of COVID-19-related CS [ 100 , 101 ]. The underlying mechanisms of MINOCA, albeit theoretical, are largely underinvestigated due to difficulties in performing invasive and noninvasive diagnostic work-up including intravascular imaging, pharmacological provocative test, and cardiac magnetic resonance [ 102 – 104 ].…”

Coronary artery aneurysm: A review

“…Several published cases reported the presence of thrombus inside the aneurysm[ 46 , 47 ] and described myocardial wall motion abnormalities following distal embolization in patients with CAA[ 48 ]. Theoretically, CAA does not have enough intact smooth muscle to produce significant vasoconstriction knowing that smooth muscle hypercontractility is implicated in the pathophysiological mechanism of coronary artery spasm[ 49 ]. However, Bove et al [ 50 ] were the first to describe a recurrent angina linked to spasm of aneurysmal coronary arteries.…”