Increased frequency of angina attacks caused by switching a brand-name vasodilator to a generic vasodilator in patients with vasospastic angina: Two case reports

Goto-Semba, Remi; Fujii, Yukihiko; Ueda, Toshihisa; Oshita, Chikage; Teragawa, Hiroki

doi:10.4330/wjc.v10.i3.15

Cited by 7 publications

(6 citation statements)

References 12 publications

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“…Third, the follow-up rate was inadequate, which might have affected the prognoses. Furthermore, only the number of coronary dilators, type of drug [ 26 ], whether the drug was generic or not [ 27 ], and frequency of mediation were evaluated, which might have affected the chest symptoms. Fourth, among the 25 patients who were not induced by the second SPT, the final dose of ACh provocation was not high but rather moderate.…”

Section: Discussionmentioning

confidence: 99%

Clinical Characteristics and Prognosis of Patients with Vasospastic Angina Subjected to the Spasm Provocation Test and the Unavoidable Use of Nitroglycerin

Teragawa

Oshita

Uchimura

2023

JCDD

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Background: Multi-vessel spasm (MVS) has a prognostic impact in patients with vasospastic angina (VSA). Thus, the presence of coronary spasm in both the left coronary artery (LCA) and right coronary artery (RCA) should be assessed through the spasm provocation test (SPT). Nitroglycerin (NTG) is used to avoid SPT-related complications; however, this unavoidable use of NTG may decrease the detection of MVS. Therefore, we investigated the frequency of the unavoidable use of NTG during SPT and clarified the clinical characteristics in patients with VSA who underwent the unavoidable use of NTG during STP. Methods: A total of 141 patients with positive SPT were evaluated. A positive SPT was defined as > 90% constriction in epicardial coronary arteries in response to acetylcholine, accompanied by the usual chest symptoms and/or ischaemic ST-T changes on electrocardiography. When a coronary spasm occurred, we usually wait for the spontaneous relief of the coronary spasm. However, if a prolonged coronary spasm or unstable haemodynamics occurred, 0.3 mg NTG was administered intracoronarily to promptly relieve the coronary spasm and this was defined as the unavoidable use of NTG. Even when the unavoidable use of NTG was administered in one coronary artery, an additional SPT was performed on another coronary artery. If a coronary spasm occurred in another coronary artery, a positive SPT was diagnosed. In contrast, if a coronary spasm was not induced after the unavoidable use of NTG, the judgement was classified as undiagnosed. The patients were divided into two groups according to the unavoidable use of NTG: U-NTG (n = 42) and the final use of NTG: F-NTG (n = 99). The clinical characteristics and frequencies of MVS (≥2 major coronary arteries in which a coronary spasm was provoked) and complications (malignant arrhythmia and unstable haemodynamics requiring catecholamines) during the SPT were compared between the groups. Results: Except for smoking status, all other clinical characteristics did not differ significantly between the groups. More current smokers were observed in the U-NTG group (29%) than in the F-NTG group (12%, p = 0.02). The frequency of MVS did not vary significantly between the groups (p = 0.28), with 64% for U-NTG and 55% for F-NTG. No significant difference was found between the groups in the frequency of severe complications during SPT (p = 0.83), with 2% for U-NTG and 3% for F-NTG. In the U-NTG group, the positive induction rate of coronary spasm in another coronary artery was 40% (17/42). Conclusions: The unavoidable use of NTG occurred in ~30% of patients with VSA, most of whom were current smokers. It did not decrease the detection of MVS and potentially prevented severe complications during SPT. Therefore, the unavoidable use of NTG is acceptable during SPT. However, an additional test may need to be performed to assess the presence of MVS.

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Section: Discussionmentioning

confidence: 99%

Clinical Characteristics and Prognosis of Patients with Vasospastic Angina Subjected to the Spasm Provocation Test and the Unavoidable Use of Nitroglycerin

Teragawa

Oshita

Uchimura

2023

JCDD

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“…Even in patients with MVS, an abnormal heart rate variability decrease within 1 month [ 25 ]. In addition, we checked only the number of coronary vasodilators in this study, but not the kinds, doses, and presence of generic forms of coronary vasodilators, which may affect the prognosis or occurrence of anginal attack in patients with VSA [ 30 , 31 ]. Furthermore, lifestyle modifications for smoking or emotional stress were not also checked; these were important prognostic factors for coronary spasm [ 32 , 33 ].…”

Section: Discussionmentioning

confidence: 99%

Clinical Characteristics and Prognosis of Patients with Multi-Vessel Coronary Spasm in Comparison with Those in Patients with Single-Vessel Coronary Spasm

Teragawa

Oshita

Uchimura

2022

JCDD

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(1) Background: We have sometimes experienced patients with vasospastic angina (VSA) who presented multi-vessel spasm (MVS) on coronary angiography and spasm provocation test (SPT). However, the clinical characteristics of VSA patients with MVS and the prognosis of such patients in the clinical setting have not been clarified. Therefore, we compared the clinical characteristics and prognosis in VSA patients with MVS with those in VSA patients with single-vessel spasm (SVS). (2) Methods: A total of 152 patients (mean age, 67 years, 74 men and 78 women) with VSA, in which the presence of coronary spasm was assessed in both left coronary artery (LCA) and right coronary artery (RCA) on SPT, were enrolled. We defined VSA as the presence of >90% narrowing of the epicardial coronary artery on angiograms, accompanied by usual chest symptoms and/or ischaemic ST-T changes on the electrocardiogram. On SPT, MVS was defined as the presence of spasms on ≥2 major coronary arteries. Based on the presence of MVS, patients were divided into the MVS group and the SVS group. The frequencies of conventional coronary risk factors, blood chemical parameters, average times of anginal attack, SPT findings such as spasm provocation induced by a low dose of acetylcholine (L-ACh) and total occlusion due to coronary spasm (TOC), number of coronary vasodilators at discharge and major cardiovascular events (MACE, including cardiac death and readmission due to any cause of cardiovascular diseases) were compared between the two groups. (3) Results: The MVS and SVS groups were comprised of 98 (64%) and 54 (36%) patients, respectively. The level of fasting blood glucose (FBS) was lower (p < 0.01), and the level of cystatin-C (n = 89) tended to be higher (p = 0.07) in the MVS group than in the SVS group. The frequencies of L-ACh-induced coronary spasm (33% in MVS and 17% in SVS, p = 0.04) and TOC (12% in MVS, 0% in SVS, p < 0.01) were higher in the MVS group than in the SVS group. The average number of coronary vasodilators at discharge was higher in the MVS group (1.2 ± 0.4) than in the SVS group (0.9 ± 0.5, p < 0.01). The frequency of MACE was not different between the two groups. (4) Conclusions: Patients with MVS may have higher VSA activity on SPT and have more aggressive medications, leading to a comparable prognosis in VSA patients with SVS. MVS is an important indicator of at least VSA activity, and cardiologists should confirm this in SPT whenever possible. Further studies should confirm whether lower FBS levels and higher cystatin-C levels are any markers of MVS.

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“…The low follow-up rate of the patients in this study and our aggressive medication approach may have contributed to these results. These results may also have been affected by the types of vasodilators used, the timing and frequency of their use, and whether they were brand-new or generic types of vasodilator[ 18 , 20 ]. However, even when these factors are taken into consideration, the severity and/or degree of chest symptoms before SPT may not reflect the long-term prognosis.…”

Section: Discussionmentioning

confidence: 99%

Clinical significance of prolonged chest pain in vasospastic angina

Teragawa¹,

Oshita²,

Orita³

2020

WJC

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BACKGROUND Patients with vasospastic angina (VSA) sometimes experience prolonged chest symptoms. The clinical characteristics of these patients have not been clarified. AIM To investigate the clinical characteristics of prolonged VSA patients. METHODS This study included 167 patients with VSA diagnosed by spasm provocation tests (SPTs) using acetylcholine, which recorded the frequencies of positive reactions to a low dose of acetylcholine (L-ACh), total occlusion due to spasm (TOC), focal spasm, and the unavoidable use of nitroglycerin (unavoidable-NTG) during SPTs. The patients underwent a medical interview that investigated the maximum duration and frequency of chest symptoms as well as the frequencies of variant angina and other serious symptoms. The patients were divided into two groups based on the maximal duration: The short-duration group (< 15 min; n = 114) and the long-duration group (≥ 15 min; n = 53). They were also divided into two groups based on the frequency of chest symptoms: The low-frequency group (< 4/mo; n = 88) and the high-frequency group (≥ 4/mo; n = 79). RESULTS The long-duration group showed higher frequencies of other serious symptoms ( P < 0.001) and variant angina ( P < 0.05) as well as higher frequencies of spasm induction by L-ACh ( P < 0.05), TOC ( P < 0.05), focal spasm ( P < 0.01), and unavoidable-NTG ( P < 0.01) than the short-duration group. These parameters did not differ significantly between the low-frequency and high-frequency groups. CONCLUSION These findings suggest that patients with VSA who experience prolonged chest symptoms may have more severe characteristics of VSA.

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Increased frequency of angina attacks caused by switching a brand-name vasodilator to a generic vasodilator in patients with vasospastic angina: Two case reports

Cited by 7 publications

References 12 publications

Clinical Characteristics and Prognosis of Patients with Vasospastic Angina Subjected to the Spasm Provocation Test and the Unavoidable Use of Nitroglycerin

Clinical Characteristics and Prognosis of Patients with Vasospastic Angina Subjected to the Spasm Provocation Test and the Unavoidable Use of Nitroglycerin

Clinical Characteristics and Prognosis of Patients with Multi-Vessel Coronary Spasm in Comparison with Those in Patients with Single-Vessel Coronary Spasm

Clinical significance of prolonged chest pain in vasospastic angina

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