Intracoronary Acetylcholine Provocation Test via Coronary Bypass Graft

Abstract

elevated. He then underwent urgent coronary angiography due to suspicion of non-ST-segment elevation ACS, which showed total occlusion in the proximal native left descending coronary artery (LAD) and LCx, and subtotal occlusion in the RCA, with all patent grafts. He was discharged with initiation of β-blocker therapy (carvedilol).Two weeks after the event, he visited the emergency room with recurrent rest angina. ECG after relief of chest pain showed no specific abnormality. Thus, the patient was scheduled to undergo ACh provocation test. Although injection of 20 and 50 μg ACh into the SVG induced vasospasm in neither the SVG nor native coronary arteries (i.e., the RCA and LCx), increasing doses of 20, 50 and 100 μg ACh into the LITA provoked not LITA spasm but vasospasm in the distal LAD, accompanied by ECG change of ST depression with negative T wave in leads V2-V4 with chest pain (Figure). The patient was diagnosed with vasospastic angina, and calcium channel blocker and long-acting nitrate were initiated. The post-discharge clinical course V asospastic angina is an important cardiac disorder that can induce acute coronary syndrome (ACS), ventricular arrhythmia, and sudden cardiac arrest. 1 Although intracoronary acetylcholine (ACh) provocation test is a validated method to diagnose vasospastic angina, 2 little is known about ACh provocation via coronary bypass graft.A 78-year-old Japanese man with rest angina was referred to the present institution. He had a history of hypertension and dyslipidemia, and had undergone coronary artery bypass grafting (CABG) at the age of 70. The left internal thoracic artery (LITA) had been grafted to the first diagonal branch, and saphenous vein grafts (SVG) had been grafted to graft the right coronary artery (RCA) and left circumflex artery (LCx). He took aspirin, angiotensin receptor blocker, and statin. At the current presentation his vital signs were normal, but an electrocardiogram (ECG) showed ST depression with negative T wave in leads V2-V4. Echocardiogram was normal, and cardiac troponin was not IMAGES IN CARDIOVASCULAR MEDICINEAdvance Publication by-J-STAGE

Mid-Right Coronary Artery Spasm Diagnosed by an Ergometrine Provocation Test Through a Saphenous Vein Graft

“…Although a previous report demonstrated a pharmacological provocation test through a left internal mammary artery bypass graft ( 3 ), a pharmacological provocation test through a coronary artery bypass graft has not yet been well established, which could be caused by the estimated low prevalence of coronary artery spasm in patients with extensive atherosclerosis. However, as reported herein, coronary artery spasm could be a cause of ACS even in patients with a history of CABG.…”