Recommendations for use of ergonovine to provoke coronary artery spasm

Abstract

TO THE EDITORErgonovine is in widespread use as a test to evoke coronary artery spasm. In patients without variant angina undergoing catheterization, ergonovine produced minimal (approximately 18%) generalized decrease in coronary artery diameter 111. This decrease in diameter is usually not associated with reduction in coronary flow or with abnormal lactate metabolism [2,3]. In patients with variant angina the response to ergonovine is much more pronounced and often results in either total, or near-total, focal or diffuse narrowing of one or more epicardial vessels. This response is associated with reduction in regional coronary flow [3], usually (but not always) followed by ST segment elevation and chest pain. Ventricular arrhythmias andor heart block are not uncommon. These responses occur with low doses of ergonovine-ingeneral, I 0.1 mg--and support the concept that variant anginapatients have altered coronary artery sensitivity to certain vasoconstrictor stimuli [4]. Often, responses to ergonovine appear remarkably similar to spontaneous episodes of coronary artery spasm [4,5]. These observations have generated numerous questions relative to the clinical use of ergonovine to test for coronary spasm. Some of the more important and frequently asked questions follow: 1) Which patients should be tested for spasm? 2) Is the test safe? 3) What protocol should be used?Results from the initial 130patients tested in our laboratories are summarized, according to their clinical presentation, in Figure 1. We have now tested over 350 patients with ergonovine, and our experience has been similar. Ergonovine evokes spasm in almost all patients with clinical findings of variant angina if they are tested during an active phase of their disease. Testing patients with other chest pain syndromes appears to have a relatively low yield (approximately 2%), implying that coronary artery spasm, at least the type evoked by ergonovine, does not play a role in the genesis of chest pain in the large majority of these patients [61. Therefore, ergonovine seems to be more useful to confirm the presence of spasm in patients with findings suggesting variant angina when, for some reason, spontaneous pain with ST segment shifts andor reversible coronary artery narrowing have not been documented. Additionally, ergonovine may be useful in determining the location and extent (vessels involved, diffuse or focal) of spasm, since some preliminary information suggests that these could be important relative to either prognosis or patency of planned aortocoronary bypass grafts. Information is not available relative to the possible usefulness of ergonovine in the evaluation of other patient subsets such as those with evolving myocardial infarction or ST elevation without chest pain.In our experience, and in approximately 1 ,OOO total cases in the literature, the test has been safe. Recently, however, five cases of "refractory" ergonovine-induced coronary artery spasm have been reported 173. These patients, collected from multiple centers, did not respon...

Frequency of provoked coronary arterial spasm in 1089 consecutive patients undergoing coronary arteriography.

“…We strongly advise that the test be performed in a room with angiographic facilities where it is possible to recognize severe atherosclerotic lesions such as extreme narrowing of the left main coronary artery, and thus avoid performing the test in these cases. 26 Angiography is the only means of obtaining direct proof of spasm and it is essential to terminate the spasm as quickly as possible once it has been documented. When the test is performed without angiographic facilities, reversal of spasm by nitrates is only done when ECG changes have been observed, and this is always later than anatomic change in the coronary vessel.…”

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“… 11 These results led us to argue against the “routine use of nitroglycerin prior to coronary angiography” since its use would remove the possibility of documenting spontaneous CAS. 8 , 11 , 12 , 13 , 14 , 15 , 16 , 17 We studied most of the medications used for coronary spasm, often before they were approved for that indication. 18 , 19 , 20 , 21 , 22 …”