Diffuse and Severe Left Ventricular Dysfunction Induced by Epicardial Coronary Artery Spasm

Abstract

Endothelial dysfunction and effectiveness of treatment of calcium antagonists are suggestive of coronary artery spasm as an underlying disorder in dilated cardiomyopathy (DCM). The aim of this study is to determine whether or not the epicardial coronary artery spasm can induce severe cardiac dysfunction like DCM. Thirty-four consecutive patients with angiographically normal coronary arteries and diffuse left ventricular hypokinesis whose causes had been unknown underwent acetylcholine provocation test and left ventricular biopsy. Eight patients were excluded according to the clinical and laboratory data and biopsy findings suggesting myocarditis or other systemic diseases. According to the results of the acetylcholine provocation test, 17 patients were finally diagnosed as having DCM, and nine patients (35% of the study patients), who had acetylcholine-induced diffuse and multivessel coronary spasm, were diagnosed as having DCM-like vasospastic angina pectoris (VSA). Clinical and cardiac catheterization data including hemodynamics and biopsy findings were similar between the two groups except that left ventricular end-systolic volume was significantly greater in DCM than in DCM-like VSA. After the acetylcholine provocation test, DCM patients received both a beta blocker and an angiotensin-converting enzyme inhibitor, and DCM-like VSA patients received antianginal drugs. In echocardiographic findings at predischarge and those after 6-month drug treatment, both DCM-lke VSA and DCM showed significant reduction in end-diastolic and end-systolic diameters and significant increase in fractional shortening and ejection fraction, whereas changes in ejection fraction and fractional shortening were significantly greater in DCM-like VSA than those in DCM. Epicardial coronary artery spasm can induce diffuse and severe left ventricular dysfunction like DCM in VSA. Although antianginal drugs markedly improve left ventricular function of these patients, only the acetylcholine provocation test can identify DCM-like VSA.

Effects of Anti-vasospastic Agents in Japanese Patients with Dilated Cardiomyopathy and Coronary Vasospasm.

“…Shimizu, et al 1) also reported that 2 of 7 DCM patients with coronary vasospasm had atrial fibrillation and 1 of 7 DCM patients with coronary vasospasm had atrial flutter. Although Sakata, et al 2) reported that only acetylcholine provocation testing can identify patients with DCM and coronary vasospasm, the present study suggests that male DCM patients with atrial arrhythmia, especially atrial fibrillation, may be related to the complication of coronary vasospasm. The possibility remains that ischemia and/ or a change in hemodynamics due to repetitive coronary vasospasms may induce atrial fibrillation.…”

“…We hypothesize that if the patients in the study by Nosaka, et al underwent the 75% ergonovine provocation testing protocol used in the present study, the prevalence of coronary vasospasm might be higher. On the other hand, the differences in the drug for induction of coronary vasospasm (i.e., ergonovine vs. acetylcholine) may be another cause, as Sakata, et al 2) reported that the prevalence of coronary vasospasm in patients with DCM is 35%. Characteristics of patients with DCM and coronary vasospasm: The prevalence of atrial fibrillation in the DCM patients with coronary vasospasm was greater than in those without coronary vasospasm.…”

Impact of Delta-Sarcoglycan Gene Polymorphism on the Occurrence of Coronary Spastic Angina in Japanese Patients With Hypertrophic Cardiomyopathy

“…25 It has been reported that CSA might cause heart failure similar to dilated cardiomyopathy. [26][27][28][29] These reports suggested that myocardial ischemia because of coronary spasm in HCM might play a potential role for the conversion of HCM to dilated cardiomyopathy. The transition from HCM to the dilated state is a critical prognostic factor in patients with HCM.…”

“…30 Previously, several reports have shown that vasodilating agents, including calcium-channel blockers and nitrates, could improve cardiac dysfunction as a result of CSA. [26][27][28][29] Because calcium-channel blockers improved vascular dysfunction and prevented progression of cardiomyopathy in sarcoglycan-deficient animals, 31,32 calcium-channel blockers could be clinically effective medications for Japanese HCM patients. Coronary spasm might be a crucial event leading to myocardial ischemia, heart failure and cardiac sudden death in patients with HCM.…”

High Prevalence of Cardiac Parvovirus B19 Infection in Patients With Isolated Left Ventricular Diastolic Dysfunction

“…31 Therefore, ischemic changes, eg, by coronary vasospasms, whether silent or symptomatic, can cause reduced wall motion and/or isolated cardiac contractile dysfunction, including diastolic dysfunction and progression of cardiomyopathy. 32,33 Myocardial inflammation is associated with endothelial dysfunction. 34 In particular, the high prevalence of PVB19 infection in acute myocarditis patients with the clinical presentation of acute myocardial infarction in the absence of relevant coronary artery stenoses suggests that this infection mode may contribute to coronary dysfunction and/or vasospasm.…”