Noninvasive Prediction of Angiographic Spasm Provocation Using Trans-Thoracic Doppler Echocardiography in Patients With Coronary Spastic Angina

Abstract

oronary spastic angina (CSA) causes myocardial ischemia at rest by abnormal contraction of epicardial coronary arteries without organic stenosis, which often occurs between midnight and early in the morning. 1 The diagnostic accuracy of noninvasive modalities for CSA, such as the cold pressor test or hyperventilation test, has been low, 2 so angiographic assessment in conjunction with spasm-provocation by intracoronary injection of acetylcholine has been the most standard, albeit an invasive, method of diagnosis. 3 However, it may sometimes lead to a serious adverse outcome. 4 The basal coronary arterial tone is increased in patients with CSA. 5,6 Because coronary flow velocity (CFV) is inversely related to lumen size in the distal myocardial bed, 7 elevated basal arterial tone can be assessed as higher flow velocity in the coronary artery. Transthoracic Doppler echocardiography (TTDE) enables reliable measurement of CFV and its reserve (CFVR) in the human left anterior descending artery. 8 We have previously reported that measuring the change of CFVR following nitroglycerin (NTG) administration is useful for assessing basal coronary arterial tone. 9 Accordingly, we evaluated the usefulness of TTDE for noninvasive diagnosis of CSA by assessing coronary arterial tone in the morning. Methods Study Patients and Study DesignWe studied 50 consecutive patients with chest pain at rest who underwent planned coronary angiography and had no significant stenoses. Two patients were excluded because of suboptimal TTDE measurements. A total of 48 patients (age 40-77 years, mean 59.8±9.1; 28 males, 20 females) were included for further analysis.The Institutional Review Board approved the study, and the patients provided written informed consent. Vasodilators were withdrawn at least 72 h before the study, except sublingual NTG, which was withdrawn at least 2 h before the study. The patients fasted overnight and did not smoke within 2 h prior to the study. All foods or drinks containing flavonoids, catechins or caffeine were withheld during the study. The Doppler examinations were performed prior to the cardiac catheterization in the morning. CFV MeasurementsTTDE was performed with 5-MHz transducer connected to Vivid 7 echocardiographic machine (GE-Vingmed Ultrasound, Horton, Norway), by an experienced investigator. The distal left anterior descending artery was examined using color Doppler mapping with a velocity ranging from -15 to +15 cm/s. After positioning a sample volume where the ultrasonic beam was as parallel to the direction of the distal part of the left anterior descending artery as possible,

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“…Interestingly, however, TFC values were unchanged in the positive ACh group when intra-coronary ISDN was administrated in the present study. We previously reported that the patients with a positive result of the ACh provocation test had significantly higher resting Tmn values compared with those without (1.18 ± 0.51 vs. 0.75 ± 0.31 s, p < 0.001) [10], as well as other previous studies [9,32,33]. In addition, a recent European multi-center study evaluating the diagnostic ability of the "ACh rechallenge" to detect coexisting microvascular spasm among patients with epicardial spasm showed that micro-vascular spasm remained after intracoronary administration of ISDN during ACh provocation test in approximately 70% of study patients [34].…”

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“…3 Thus, he proposed "an increased tonus" at the site of a subcritical stenosis as the likely cause of the syndrome. 7 Subsequently, variant angina was described by Cheng et al also in patients with angiographically normal coronary arteries and defined "the variant of the variant", 8 thus falsifying the paradigm that a stenosis was required for the development of spasm. However, 15 years after the publication of the Prinzmetal report, there was a prevailing scepticism at the World Congress of Cardiology in Buenos Aires in 1974, after the presentation of the angiographic findings of 3 cases of occlusive spasm abolished by nitrates by Maseri's group: most of the audience believed that spasm was an artefact induced by the catheter!…”