Diagnosis of Multivessel Coronary Vasospasm by Detecting Postischemic Regional Left Ventricular Delayed Relaxation on Echocardiography Using Color Kinesis

Abstract

pisodes of coronary vasospasm are characterized by transient myocardial ischemia resulting from the temporary obstruction to coronary flow followed by reperfusion. Regional left ventricular (LV) diastolic dysfunction or delayed relaxation with prolonged isovolumic relaxation time may follow the transient, severe myocardial ischemia associated with coronary vasospasm and persist well beyond the recovery of the regional systolic dysfunction. 1-3 Color kinesis (CK) (Philips Medical Systems) is a new technique based on acoustic quantification that has been recently developed to facilitate the evaluation of regional wall motion (RWM). [4][5][6] Using this method we recently reported that impaired or stunned regional diastolic function after ischemia occurs commonly in patients with coronary vasospasm. 7,8 Okumura et al reported that in patients with variant angina (VA), intracoronary injection of acetylcholine (ACh) can induce spasm in each susceptible artery separately and that the incidence of multivessel coronary spasm is surprisingly high in these patients. 9 However, it is controversial whether multivessel coronary Circulation Journal Vol. 68, May 2004 spasm occurs spontaneously in these patients.The aim of the present study was to use CK to detect multiple sites of regional LV delayed endocardial wall motion during diastole to determine whether multivessel coronary spasm actually occurs spontaneously in patients with VA and demonstrated multivessel spasm induced by ACh. Methods Study PatientsOf 33 consecutive patients with VA in whom the inducibility of spasm of both the left and right coronary arteries was evaluated during cardiac catheterization, 7 who did not have good acoustic windows or adequate tracking by CK were excluded and the remaining 26 (19 men, 7 women; mean age, 62±9 years; range: 37-77 years) were the subjects of the present study. Electrocardiographic ST-segment elevation during at least an episode of angina was confirmed in all the patients. The CK study was performed within 1 week (3±2 days) prior to the coronary arteriography examination following a spontaneous angina attack. Patients with rhythm or conduction disturbances, a significant (>75% luminal diameter) organic coronary stenosis, apparent systolic regional LV dysfunction, LV hypertrophy or severe hypertension, were not included in the present study nor were patients without coronary spasm induced by ACh. In all patients coronary artery spasm Background It is not known whether multivessel coronary spasm occurs spontaneously in patients who have variant angina (VA) with demonstrated multivessel spasm induced by intracoronary injection of acetylcholine (ACh). Regional left ventricular (LV) diastolic dysfunction or wall motion abnormality may persist after an episode of coronary vasospasm. Color kinesis (CK) is a recent development that facilitates the echocardiographic evaluation of regional diastolic wall motion. Methods and ResultsRegional diastolic wall motion was evaluated using CK in 26 patients with VA within 1 week of the last...

Effects of Postischemic Regional Left Ventricular Diastolic Wall Motion Abnormalities or Delayed Relaxation Following Coronary Vasospasm on Global Diastolic Function

“…The CK-diastolic index was defined as the LV segmental filling fraction during the first 30% of the diastolic filling time (LV segmental cavity area expansion during the first 30% of diastole, divided by the segmental end-diastolic LV cavity area expansion, expressed as a percentage). [12][13][14] The mean CK-diastolic indexes in 40 age-matched control subjects were 71±6, 72±7 and 75±7% in the territory of AS, LAT and INF, respectively. Intraobserver variability of the CK-diastolic index was 6.5±3.4% (n=18).…”

“…A custom software program was used to extract endocardial expansion for myocardial segments in the LV midpapillary shortaxis view, as reported previously. [12][13][14]16,17 The timing of color encoding was set to begin at the first frame in which outward endocardial motion was noted, and its duration was set to its maximal value (33 ms × 19 frames). The sites of regional LV diastolic wall motion or regions of interest were set on the basis of standard segmentation models corresponding to the 3 major coronary perfusion territories assigned as follows (Fig 1) 18 : (i) the anterior and anteroseptal segments (AS) to the left anterior descending coronary artery (LAD); (ii) the anterolateral and posterolateral free wall segments (LAT) to the left circumflex branch (LCX) or the diagonal branches originated from LAD; and (iii) the posteroseptal and inferior segments (INF) usually to the right coronary artery (RCA).…”

“…10,11 Recently, we have found using this method, that impaired or stunned regional diastolic function with delayed outward wall motion persisted beyond recovery of ischemia commonly in patients with coronary vasospasm. [12][13][14] This diastolic dysfunction is specifically caused by postischemic damage because it is completely recovered. The present study was designed to determine how the global diastolic function was affected by impaired regional LV wall motion or diastolic asynchrony following coronary vasospasm in patients with single or multivessel coronary vasospasm.…”

“…Some patients had been involved in previously reported studies. [12][13][14] In all patients, coronary artery spasm (transient total or subtotal occlusion) associated with ST segment elevation (≥0.1 mV) on the electrocardiogram and/or typical chest pain was angiographically demonstrated in at least one of the major coronary arteries during angina and was provoked by an intracoronary injection of acetylcholine. 15 The spasm was relieved spontaneously within 2 min or otherwise by intracoronary administration of isosorbide dinitrate.…”

Strain Measurements During Adenosine Triphosphate Infusion Before and After Percutaneous Coronary Intervention

“…Ishii et al reported that delayed relaxation or delayed contraction is observed in patients with vasospastic angina for several weeks after attack of spasm on color kinesis. 24, 25 The ischemic memory in myocardial contraction is thought to remain for hours or days or weeks. 5,26,27 This ischemic memory is explained by the delay of metabolic stunning even after blood flow restoration.…”