New Protocol to Detect Coronary Spastic Angina without Fixed Stenosis.

Abstract

SUMMARYA new combined test, accelerated exercise following mild hyperventilation (HV), was examined to determine whether it is effective at detecting a positive response in patients with pharmacologically-induced coronary vasospasm and near normal coronary arteries.Fifty-eight consecutive patients who underwent both triple non-invasive spasm provocation tests and diagnostic coronary angiography were enrolled. They all had pharmacologically-induced coronary vasospasms and no significant organic stenosis. In these patients, an HV test was performed first, followed by a treadmill exercise test (TET), and finally the new combined test under no medication within 3 days. Of the 58 patients, positive responses were observed in 9 patients to the HV, in 15 to the TET, and in 35 to the newly combined test. The remaining 21 patients had negative responses although the triple sequential tests were perfomed. Thus, the sensitivities of the HV test, TET, and newly combined test were 16% (9/58), 26% (15/58), and 63% (35/56), respectively. Forty-six subjects with near normal coronary arteries and no ACh-provoked spasm served as controls. None of these subjects had positive responses to any of these three tests, and thus their specificity was all 100%. No serious or irreversible complications were seen in this study.We recommend this newly-combined protocol for the induction of coronary artery spasm in patients with vasospastic angina pectoris and without significant stenosis as a diagnostic tool. (Jpn Heart J 2002; 43: 307-317) Key words: Coronary spastic angina, Exercise test, Hyperventilation HYPERVENTILATION (HV), cold stress, and exercise tests have been clinically performed as non-invasive provocation tests for coronary vasospasm, [1][2][3][4][5] whereas invasive provocation tests, such as intracoronary injection of acetylcholine (ACh) or ergonovine (ER) are performed to diagnose patients with coronary spastic angina in the cardiac laboratory.6-11) However, due to circadian variaFrom the

Overview of the Non-Invasive Examinations in Patients with Coronary Spastic Angina

“…The new combined protocol, which consisted of 5 min of mild hyperventilation with a frequency of 24 breaths/min to 40 breaths/min followed by the modified treadmill exercise test accelerated every minute of Bruce's protocol, was the most useful method to obtain the positive rate [10]. In 58 patients with CSA without fixed stenosis, the positive frequency by the new combined protocol (63%) was significantly higher than the standard treadmill exercise test (26%) or hyperventilation test (16%), as shown in Figure 1 [12]. In contrast, we obtained the significantly higher positive response by the new combined protocol (84%) than that by standard treadmill exercise test (40%) or hyperventilation test (16%) in 40 patients with fixed stenosis and coronary artery spasm, as shown in Figure 1 [11].…”

“…However, before performing the coronary angiography, it may be prefered by cardiologists to obtain ischemic findings in these patients. As a non-invasive examination treadmill exercise test, hyperventilation test and cold pressor test were employed for the induction of ischemia due to coronary artery spasm [4][5][6][7][8][9][10][11][12][13]. In patients with ischemic heart disease and obstructed coronary artery disease, treadmill/bicycle exercise tests are very useful to obtain the pathologic findings, whenever it may be difficult to obtain the ischemic findings to perform treadmill exercise tests in patients with coronary spastic angina (CSA) and non-obstructed coronary artery disease.…”

Severity of Myocardial Fatty Acid Dysmetabolism Induced by Coronary Spasm Does not Differ With Thrombolysis in Myocardial Infarction (TIMI) Grade During Intracoronary Acetylcholine Provocation Tests

“…Positive coronary spasm induced by provocation tests is defined as ≥ 99% luminal narrowing 9,10,12,24,25) because the key to a diagnosis of VSA is to document a severe ischemic attack, such as ST-segment elevation. Here, we demonstrated that critical coronary spasms with TIMI 3 grade flow are associated with altered myocardial fatty acid metabolism.…”

Approximately half of patients with coronary spastic angina had pathologic exercise tests

“…Non-invasive tests as well as invasive testing are employed as diagnostic methods. Treadmill exercise tests, hyperventilation tests, and cold stress tests are used for the induction of ischemia due to coronary artery spasm as a non-invasive examination [3][4][5][6][7][8][9][10][11][12][13][14][15]. In patients with ischemic heart disease and obstructed coronary artery disease, treadmill exercise tests are useful to obtain the pathologic findings; however, they may not be so useful to detect the ischemic findings in patients with CSA and nonobstructed coronary artery disease.…”