Overview of the Acetylcholine Spasm Provocation Test

Abstract

The acetylcholine (ACh) spasm provocation test proposed by Yasue, Okumura et al more than a quarter‐century ago has become a popular method for induction of coronary spasm. This test is safe and has a low rate of complications. However, it may be limited in its ability to document attacks in daily life because previously it was the gold‐standard method for diagnosing active variant angina. There may be some clinical issues to modify for the next generation of cardiologists. A maximal ACh dose of 50/100 µg in the right coronary artery/left coronary artery is recommended in the Japanese Circulation Society guidelines. We often experienced the usefulness of a maximal ACh dose of 80/200 µg for the induction of coronary spasm in some cases with low or moderate disease activity. It may be necessary to reconsider the maximal ACh dose as a modified method for today's real‐world clinical practice. In young patients with rest angina, intracoronary injection of ACh is less sensitive for diagnosis; in these cases, we recommend performing sequential spasm provocation tests. Especially in female patients, to document coronary artery spasm we recommend performing ACh tests first, instead of ergonovine tests, due to the supersensitivity of ACh. We also recommend supplementary use of ACh and ergonovine. This review summarizes our experiences with the ACh spasm provocation test over a period of 24 years. We have found it to be a reliable and useful method for contributing a variety of clinical information and recommend it to the next generation of cardiologists.

Intracoronary Acetylcholine Provocation Testing – Omission of the 20-µg Dose Is Feasible in Patients Without Coronary Artery Spasm in the Other Coronary Artery –

“…Furthermore, the usefulness of higher doses of ACh such as 80 μg for the RCA and 200 μg for the LCA has recently been demonstrated. 7,11,12 In the present study, 2 cases of ventricular tachycardia and one of cardiogenic shock were documented, and all of them were induced by the maximum dose of ACh for each of the coronary arteries (LCA and RCA). Therefore, it is suggested that the first target artery should always be examined with incremental doses of ACh to avoid serious complications, because the provocation test by the incremental doses may be able to detect the threshold of vasospastic activity in individual patients.…”

Intracoronary Acetylcholine Provocation Test via Coronary Bypass Graft

“…5 Thus, injection doses of ACh via the LITA in the present case may be acceptable, and the test was performed without any complications.…”

Usefulness of a Pressure Wire for the Diagnosis of Vasospastic Angina during a Spasm Provocation Test

“…Recently, the usefulness of higher ACh doses in SPTs has been reported [5,18,19]. Since these reports, SPTs using higher ACh doses have been done more frequently, even at our institution.…”

“…Although the diagnosis of VSA is usually made by the presence of characteristic chest pains and transient ST-segment changes on electrocardiography (ECG), many patients cannot be diagnosed by ECG changes alone and usually require a spasm provocation test (SPT) [3][4][5]. Despite being clinically important, this examination can be accompanied by severe complications such as shock, ventricular fibrillation, ventricular tachycardia, and bradyarrhythmia [6][7][8][9].…”