Fluctuation of spastic location in patients with vasospastic angina: a quantitative angiographic study

OBJECTIVES

This study sought to determine whether the location of coronary spastic activity may change over time in patients with persistent variant angina.

BACKGROUND

Although electrocardiographic studies have provided indirect evidence to indicate that the location of ischemia may change in patients with variant angina, it has not been tested by quantitative angiography whether the location of vasospastic activity may change over time.

METHODS

Paired ergonovine provocation tests and coronary angiography were performed at a mean (+/- SD) interval of 43 +/- 13 months apart in patients with persistent symptoms of vasospastic angina in the absence of significant atherosclerosis. A total of 87 spastic and nonspastic segments of 87 major vessels in 29 patients were analyzed by quantitative angiography at baseline, after the administration of ergonovine and after isosorbide dinitrate at the initial and follow-up tests.

RESULTS

In 13 patients (group 1), coronary spasm was observed in the same 16 coronary segments at both the initial and follow-up ergonovine provocation tests. In 16 patients (group 2), the following angiographic changes occurred between the initial and follow-up tests in 48 major vessels: Of the 23 segments that developed spasm at the initial test, 10 did not have spasm at the follow-up test; of the 25 vessels that did not demonstrate spasm on the initial test, 12 demonstrated spasm on the follow-up test (a new site of spasm). Thus, in 22 (46%) of 48 vessels, fluctuation of spastic location was observed at follow-up.

CONCLUSIONS

Quantitative coronary angiography and repeated ergonovine tests revealed that some patients with persistent vasospastic angina demonstrate fluctuation of vasospastic location, whereas others exhibit a fixed location of vasospasm. Vasospastic angina may not only be a transient disease restricted in location, but may also be a persistent and variable condition involving multiple vessels over many years.

Utility of iodine-123-BMIPP in the diagnosis and follow-up of vasospastic angina

Myocardial damage caused by vasospastic angina (VSA) may be detected by [123I]BMIPP, a beta-methyl-branched fatty acid. We investigated whether BMIPP could be used in the diagnosis and follow-up of patients with VSA.

METHODS

Thirty-two patients with VSA were studied with resting BMIPP-SPECT in comparison to stress perfusion imaging with either 201Tl or 99mTc-MIBI. During coronary arteriography, spasm was induced by provocative testing with acetylcholine or ergonovine, and only total or subtotal occlusion was considered positive. Decreased BMIPP uptake was semiquantitatively evaluated segmentally aided by polar map display.

RESULTS

Reduced BMIPP uptake was observed in 25 of 32 patients (78%), with complete or partial agreement between the BMIPP abnormality and coronary territory seen in 23 patients (72%). In contrast, a perfusion abnormality was seen in only 10 patients (31%). In the repeat BMIPP study (n = 23) during the follow-up period (average 206 days), 11 of 14 patients who showed BMIPP improvement also had improved angina attacks. Conversely, two of nine patients with nonimproved BMIPP showed improved symptoms (p < 0.05).

CONCLUSION

BMIPP can detect myocardial injury associated with VSA and may be useful in monitoring response to treatment.

[Variant angina pectoris related to the treatment of migraine]

A 54 years-old man with a history of migraine, suffered from chest pain together with ST-segment elevation related to the intake of drugs against migraine attacks. The coronary arteriography showed normal coronary arteries. We suggest coronary artery spasm as the most probable cause of ischemia. We conclude that vasoactive drugs against migraine must be utilized with caution, or even avoided in patients with chest pain suggestive of myocardial ischemia.

[Hyperventilation test: a noninvasive screening test for coronary vasospasm]

3 patients with coronary vasospasms in different clinical situations are presented. One patient had typical Prinzmetal angina but coronary arteries without significant stenosis. One patient without typical angina pectoris showed sudden significant ST elevations on anterior and lateral ECG tracings accompanied by typical ischemic chest pain. At angiography, a 70% LAD stenosis was found without high degree lesions. One patient (aged 30 years) had a documented anterior infarction with angiographically normal coronary arteries. In all these cases coronary vasospasms were recognized as the underlying cause of the symptoms. All the patients were treated with calcium channel blockers and have been asymptomatic since. Currently available data comparing the diagnostic value of hyperventilation with other tests for coronary vasospasms, such as ergonovine or acetylcholine, are discussed. The hyperventilation test can be recommended as the first test in the work up of suspected vasospastic angina pectoris.

Selective ergonovine-induced coronary artery spasm and ST-segment alternans after blunt thoracic trauma

A 24-year-old man was found to have angiographically normal coronary arteries shortly after suffering blunt thoracic trauma. Selective ergonovine administration into the left coronary artery induced total occlusion of the left anterior descending branch and electrical alternans of the ST-segment. This case demonstrates coronary artery spasm as a possible mechanism of coronary occlusion after blunt thoracic trauma.

Angina-linked syncope and lack of calcium antagonist therapy predict cardiac arrest before definitive diagnosis of vasospastic angina

BACKGROUND

Several prognostic factors have been identified in patients with vasospastic angina; however, factors that would predict potentially fatal cardiac arrest during the period between the onset of angina and its definitive diagnosis remain unknown. We investigated the predictive value of the clinical findings that are available when a patient is hospitalized after a cardiac arrest but before a definitive diagnosis of vasospastic angina is made.

METHODS

We compared the clinical findings in 11 patients who experienced cardiac arrest before vasospastic angina was definitively diagnosed (group I) with 81 patients with vasospastic angina without cardiac arrest (group II). The definitive diagnosis of vasospastic angina was made on the basis of results of coronary spasm provocation test or ECGs during spontaneous attacks, or both.

RESULTS

The incidence of angina-linked syncope was significantly higher in group I than in group II (six out of 11 versus nine out of 81, P < 0.005). Significantly fewer group I patients were receiving calcium antagonists than group II patients (three out of 11 versus 63 out of 81, P < 0.005). Serious arrhythmias were significantly more common in group 1 than in group II (seven out of 11 versus 12 out of 81, P < 0.005). Logistic regression analysis of the eight clinical variables available when first seen in the hospital indicated that angina-linked syncope and the lack of calcium antagonist therapy were independently related to risk of cardiac arrest.

CONCLUSIONS

From the clinical findings available, a history of angina-linked syncope and lack of calcium antagonist therapy were found to be independent predictors of cardiac arrest before a definitive diagnosis had been made. Patients who have suspected vasospastic angina may benefit from early treatment with calcium antagonists if they have a history of angina-linked syncope.

Values of intravenous ergonovine test with two-dimensional echocardiography for diagnosis of coronary artery spasm

The purpose of this study was to evaluate the clinical validity of the bedside ergonovine test with digital echocardiography and the side-by-side continuous cineloop display method (ergonovine echocardiography) as a noninvasive diagnostic tool for coronary artery spasm. Bedside ergonovine test was performed in 66 patients who showed coronary vasospasm during coronary angiography including provocation testing (group with variant angina) and 39 patients with normal angiograms and no evidence of coronary artery spasm (group with nonanginal pain). A bolus of ergonovine maleate (0.025 or 0.05 mg) was injected at 5-minute intervals up to total cumulative dosage of 0.35 mg, and 12-lead electrocardiography and two-dimensional echocardiography were recorded every 3 minutes after each injection. Left ventricular wall motion was analyzed with a commercially available quad system. The positive criteria of bedside ergonovine test included reversible ST segment elevation or depression on electrocardiograms (ECG criteria) and reversible regional wall motion abnormalities by echocardiography (Echo criteria). The overall sensitivity and specificity of ECG criteria were 53% (35/66; 95% confidence interval 41% to 65%) and 100%, respectively. By Echo criteria the sensitivity increased to 89% (59/66; 95% confidence interval 81% to 97%), with a specificity of 95% (37/39).(ABSTRACT TRUNCATED AT 250 WORDS)

Once daily felodipine in preventing ergonovine-induced myocardial ischaemia in Prinzmetal's variant angina

The efficacy of extended-release felodipine in preventing ergonovine-induced myocardial ischaemia was assessed in 14 patients (12 male, two female, aged 56 +/- 7 years) with Prinzmetal's variant angina. Four of the patients had normal coronary arteries, eight had one-vessel and two had two-vessel disease. The ergonovine test was performed once in basal conditions and twice 5 days after beginning the oral administration of felodipine 20 mg o.d., 4 and 24 h after the last administration. During a continuous 6-lead ECG recording, ergonovine was injected at doses of 25, 50, 100, 200, and 400 micrograms at 5 min intervals. Blood samples for felodipine plasma concentrations were drawn at the time of the tests. The basal ergonovine test was positive in all 14 patients (seven with anterior and seven with inferior ST segment elevation > 0.1 mV) at a mean ergonovine dose of 162 +/- 138 micrograms. The test was repeated 4 h after the last felodipine administration and was negative in 13 patients (93%), but 24 h after the last drug administration, eight patients (57%) had a positive test response (five with anterior, three with inferior ST segment elevation) at a higher ergonovine dose than at baseline (150 vs 97 micrograms, P = 0.042). The only differences between patients with a negative and a positive test were the mean values of the left ventricular end-diastolic pressure (9.3 vs 14.9 mmHg, P = 0.002) and the ergonovine doses used in the baseline tests (250 vs 97 micrograms, P = 0.034).(ABSTRACT TRUNCATED AT 250 WORDS)

Variant angina in an adolescent

We describe a case of variant angina associated with acute myocardial ischemia in an adolescent presenting with severe chest pain and transient ST elevation. Subsequent cardiac catheterization revealed normal coronary anatomy, and the patient has been asymptomatic since discharge on calcium channel blockers. Variant angina is a rare cause of chest pain in adolescents.

[Value of the methylergometrin maleate test in recurrent cardio-circulatory arrests]

A 56-year-old man, with no particular past history, sustained two cardio-circulatory arrests preceded by constrictive chest pain. Coronary arteriography was normal during etiological investigations. The methylergometrine maleate (Méthergin (tm)) test enabled the diagnosis of severe spastic angina and guided appropriate management of this patient.

[ST elevation during ergometric test: correlation with coronary angiography]

BACKGROUND

ST elevation during ergometric stress test (EST) is relatively rare. Its prevalence depends upon the tested population but occurs more frequently in patients who have had myocardial infarction or variant angina. This phenomenon is very rare in patients with typical exertional angina and its pathogenesis is still unclear.

MATERIAL AND METHODS

We studied a group of 75 consecutive patients with exertional angina who underwent EST and coronary angiography. A symptom limited EST was performed in the upright position on a cycloergometer with load increases of 25 watts every 3 minutes and 12 leads were monitored during all test. Coronary angiography was performed according to Judkins technique. From these patients, according to Froelicher's criteria, a group of 49 patients (age 32-68, mean 51.6 years), without myocardial infarction and/or left ventricular asynergy, was selected.

RESULTS

All patients had a coronary artery disease (16 patients with 3 vessels, 11 patients with 2 vessels and 22 patients with 1 vessel disease). The EST was positive for ST depression in 31 patients (63.3%) and for ST elevation in 5 patients (10.1%), while 13 patients (26.6%) had a non diagnostic EST. The ST elevation occurs in V1-V2 and it was associated in all cases with a stenosis in the left anterior descending (LAD) artery. Therefore we divided the 19 patients with LAD stenosis into two subgroups: subgroups A (9 patients, mean age 49.6 years) with LAD stenosis > or = 90% and subgroups B with LAD stenosis between 70% and 90%. ST elevation occurs in 5 patients (55.5%) of subgroup A and in no patient of the subgroup B. Moreover, in the subgroup A ST elevation seems to be related to the anatomic localization of the stenosis: in fact it appears in 83.3% of patients with LAD stenosis located before the onset of the first diagonal branch.

CONCLUSIONS

From these data it can be desumed that ST elevation in V1-V2 that occurs in patients with exertional angina and without myocardial infarction or variant angina is strongly predictive of a very important LAD stenosis.

Transient terminal U wave inversion as a more specific marker for myocardial ischemia

Transient U wave inversion can be caused either by regional myocardial ischemia or by an elevation of systemic blood pressure. The characteristics of U wave inversion during chest pain attacks in 21 patients with variant angina were compared with those observed in 38 patients with hypertension without apparent ischemic heart disease. Differentiation was possible according to the ECG phase in which U wave inversion appeared. U wave inversion was considered to be significant if there was a discrete negative deflection of more than 0.05 mV within the TP segment. U wave inversion proceeded to positive deflection of U wave in patients with hypertension without ischemic heart disease (initial U wave inversion). In contrast, inverted U wave occurred after positive U wave deflection during attacks in patients with variant angina (terminal U wave inversion). When cold pressor test was performed in patients with variant angina during treatment with calcium entry blockers, no patient had either anginal attacks or ischemic ST-segment deviation, but 9 of 21 patients (43%) had transient initial U wave inversion, which was followed by positive U wave deflection. U wave inversion can be classified as initial U wave inversion and terminal U wave inversion according to the phasic relationship to positive U wave deflection; the latter is observed in association with regional myocardial ischemia. The former seems to be related to elevated blood pressure rather than to myocardial ischemia.

[Contribution of Holter monitoring in the diagnosis of a case of Prinzmetal's angina]

Prinzmetal angina is a peculiar kind of angina pectoris, in which Holter monitoring has been particularly useful for diagnosis. In this paper it is reported a 56 years old male patient with coronary artery spasm induced during coronary arteriography in which the Holter electrocardiography was of most importance for decision making.

[The use of ergonovine in the hemodynamics laboratory]

In our department we have reviewed the use of ergonovine maleate as a provocative agent for inducing coronary spasm during coronary arteriography. From January 1978 to December 1991 the test has been performed in 116 patients. According to their symptoms, the patients were divided into 4 groups: (A) patients with exertional angina: 16 patients (13.8%), (B) patients with angina at rest: 64 patients (55.2%), (C) patients with atypical chest pain: 29 patients (25%), and (D) patients with previous myocardial infarct: 7 patients (6%). We have subdivided the patients with angina at rest, according to the electrocardiogram recorded during pain, into: (1) 16 patients with ST-segment elevation; (2) 14 patients with ST-segment depression or T wave inversion; (3) 5 patients with electrocardiogram unchanged during angina; (4) 29 patients with no electrocardiogram recorded during angina. In 67 patients (57.7%) the coronaries were normal, 17 patients (14.6%) had mild irregularities, 26 patients (22.4%) had non critical fixed obstructions (< or = 70%), and in 6 patients (3.5%) there were fixed coronary narrowings > or = 70%. The left ventricle was normal in 85 subjects (73.2%), hypo or akinetic in 31 (26.8%). After routine coronary angiography and ventriculography, ergonovine maleate, 0.05 up to 0.4 mg, was given intravenously. The ergonovine test was considered positive when a focal spasm narrowed a normal coronary artery, or one with a mild fixed obstruction (< or = 50%) to more than 70%, or when a 70% stenosis became occluded. The development of angina and/or electrocardiographic changes were not taken as a criteria of positivity. Thirteen tests (11.2%) were considered positive.(ABSTRACT TRUNCATED AT 250 WORDS)

Circadian fluctuations of tissue plasminogen activator antigen and plasminogen activator inhibitor-1 antigens in vasospastic angina

To elucidate the circadian variation of fibrinolytic components in vasospastic angina, plasma levels of tissue plasminogen activator antigen (t-PA), free plasminogen activator inhibitor antigen (free PAI-1), t-PA/PAI-1 complex, and total PAI-1 were measured in venous plasma samples. Samples were taken every 6 hours (6:00 AM, noon, 6:00 PM, and midnight) for 24 hours in 14 patients with vasospastic angina, in 9 patients with exertional angina, and in 19 normal subjects. Twenty-four-hour Holter monitoring (Holter monitor, Del Mar Avionics, Irvine, Calif.) was also carried out in all subjects. All of the fibrinolytic components showed circadian variation, with a peak level at 6:00 AM in every study group except for the t-PA/PAI-1 complex in the group of patients with exertional angina. The values for all or the fibrinolytic components at each sampling time were higher in patients with coronary artery disease than in normal subjects. In particular, the mean value of free PAI-1 at 6:00 AM in patients with vasospastic angina was significantly higher than that in normal subjects and that in patients with exertional angina. This value of free PAI-1 in patients with vasospastic angina was closely associated with the duration of ischemic attacks. These results suggested that the circadian fluctuation of fibrinolytic components may be an important factor that leads to coronary thrombosis at the time of coronary spasm, especially in the early morning.

[Noninvasive diagnosis of coronary spasm]

The objective of this work was to compare the sensitivity of non-invasive tests used for the diagnosis of variant angina pectoris (VAP). In a group of 38 patients with VAP the authors compare the sensitivity of the cold test (CT), hyperventilation test (HT), handgrip (HG), bicycle ergometry (BE) and a newly suggested combination of hyperventilation with HG and BE resp. The authors evaluated first the sensitivity of ST elevations which are an entirely specific sign and in particular denivelization of ST (by depression or elevation) which is a less specific sign. The sensitivity of different tests was as follows: CT 5% and 5% resp., HT 18% and 39% resp., HG 13% and 29% resp., BE 26% and 66% resp., HV+HG 37% and 63% resp., HV+BE 50% and 87% resp. Then the authors assessed the sensitivity of repeated examinations HV+HG 47% and evaluation during denivelization of ST 63%, HV+BE 66% and 89% resp. The authors evaluated moreover the sensitivity of ST elevations in patients according to the activity of the disease. Patients with at least five stenocardias per week had a higher sensitivity, as compared with patients with less frequent attacks: HV+HG 42% and 25% resp., HV+BE 60% and 33% resp. The highest sensitivity was found in a combination of HV+BE. Repetition of the test in case of a negative result increased markedly the sensitivity, a higher sensitivity was found also in patients with more frequent stenocardias.

Various 12-lead electrocardiographic findings of diffuse three-vessel coronary artery spasm

Electrocardiographic signs of diffuse three-vessel coronary artery spasm may show various findings including no ST segment changes, according to whether or not a difference of an electrical gradient develops between the anterior and inferior regions because of global ischemia. This study suggests that diffuse three-vessel coronary artery spasm must be considered when the 12-lead electrocardiogram (ECG) shows no important ST segment changes with episodes of angina and diffuse coronary artery spasm during an ergonovine provocation test in patients with strongly suspected variant angina.

[Atypical attacks of stenocardia of effort occurring at rest]

Results of a clinico-instrumental examination and treatment of 320 patients with ischemic heart disease revealed that 147 of them showed both exertion stenocardia and angina pectoris attacks in seemingly physical rest that could be considered as spontaneous stenocardia. An analysis of the clinical picture of the disease in these patients allowed to distinguish five atypical variants of effort stenocardia that imitated stenocardia during rest: hemodynamic, stenocardia during arterial pressure elevation, cardiac arrhythmia, vasospastic and night effort stenocardia attacks. A differential approach to to complex treatment of patients with the above forms of effort stenocardia is necessary.

The effect of ergonovine on coronary vasodilatory reserve in patients with angiographically normal coronary arteries

Ergonovine produces physiologic coronary artery narrowing in many patients without focal coronary spasm. The effect of ergonovine-induced coronary vasoconstriction on coronary vasodilatory reserve is unknown. Therefore we studied 10 patients with atypical chest pain and angiographically normal coronary arteries. The heart rate and blood pressure were recorded continuously and coronary Doppler flow velocity was measured continuously with a 20 MHz Doppler-tipped catheter. Ergonovine caused diffuse narrowing of the vessels in all patients, with a 12% +/- 5% change in diameter of the left anterior descending coronary artery (p less than 0.001). There was a significant change in systolic (17% +/- 12% change; p less than 0.05) and mean arterial pressure (13% +/- 13% change; p less than 0.05), with no significant change in mean coronary flow velocity with ergonovine. Ergonovine also did not attenuate the maximal hyperemic response with papaverine. Thus despite an increase in myocardial demand and a decrease in caliber of conductance coronary vessels, the coronary autoregulatory flow responses were intact after the administration of ergonovine.

[Prinzmetal angina pectoris causing diagnostic and therapeutic problems]

A 53 year old patient was hospitalized because of retrosternal oppression which was unrelated to effort and recurred in the early morning hours. An esophageal diverticulum and a hiatal hernia were found. The patient had complaints in spite of medical therapy and an operation was performed because of his oesophageal disorders. After operation the patient had the same pain. A cardiologist was asked, who suggested Prinzmetal variant angina. During arteriography coronary artery disease was found. Coronary bypass surgery was indicated and performed, after that procedure the patient was and remained free of any complaints. This observation reaffirmed Prinzmetal original statement "The key to the diagnosis ... is the taking of a painstaking history".

Biphasic changes (initial increase and late decrease) in coronary sinus venous oxygen saturation during anginal attacks induced by intracoronary acetylcholine in patients with variant angina

In order to evaluate the effects of intracoronary acetylcholine on coronary resistance vessels, oxygen saturation in coronary sinus blood was continuously measured to compare its dynamic changes during intracoronary injection of acetylcholine in both patients with variant angina and control subjects. Group 1 consisted of 6 patients without coronary artery disease. Group 2 consisted of 10 patients with variant angina and spasm in the left anterior descending coronary artery. A fiberoptic reflection oximetry system was used for the continuous measurement of coronary sinus venous oxygen saturation. Acetylcholine (20 micrograms) was injected directly into the left coronary artery over 30 s. In the group 1 patients, coronary sinus venous oxygen saturation was increased from 39 +/- 2% (mean +/- SEM) to 54 +/- 3% at 30 s, continuously climbed to 70 +/- 3% at 60 s and then gradually decreased to 53 +/- 5% at 120 s after the initiation of intracoronary injection of acetylcholine. In contrast, in the group 2 patients, coronary sinus venous oxygen saturation was transiently increased from 39 +/- 2% to 56 +/- 4% at 30 s, reversed, decreased to 52 +/- 4% at 60 s and then rapidly decreased to 36 +/- 3% at 120 s with the onset of chest pain associated with electrocardiographic ischemic changes. Coronary arteriography during attacks demonstrated a total or subtotal occlusion of the left anterior descending coronary artery due to severe spasm in all of the 10 patients. The extent of increases in coronary sinus venous oxygen saturation at 30 s after acetylcholine injection was not significantly different between the two groups (group 1: 15 +/- 4%, group 2: 17 +/- 3%). Heart rate, blood pressure and rate-pressure product were essentially unchanged at 30 s after intracoronary injection of acetylcholine in both groups. These data suggest that in control adult humans, coronary blood flow was increased through dilatation of resistance vessels by acetylcholine, while in patients with variant angina, coronary blood flow was transiently increased by dilatation of resistance vessels, after which it was suddenly decreased by spasm of an epicardial artery induced by this agent. Relaxant responses to acetylcholine of coronary resistance vessels appear to be preserved well in patients with variant angina.

[An analysis of the variability in the heart rate in relation to the presence of transient ischemia and to its physiopathological mechanism]

To assess the differences in the pathogenesis of cardiac ischemic events and the role of the autonomic nervous system, we studied the electrocardiographic measures of tonic vagal activity during 24-hour Holter monitoring. We tested the circadian rhythm of the power in the high frequency energy (HF: 0.15-0.40 Hz) of the normal R-R interval power spectrum, the daily percent of successive normal R-R greater than 50 ms (pNN50) and the roots mean square of successive difference of normal R-R intervals (MMSD) in patients with coronary artery disease of comparable angiographic severity. Group A consisted of 5 patients (mean age 62 +/- 8) with chronic stable angina and Group B of 5 patients (mean age 61 +/- 8) with variant angina. Characteristic anginal pattern, typical ST changes during ischemic events on Holter monitoring and angiographic evidence of vasoconstriction induced by hyperventilation distinguished the 2 groups. Mean Cosinor analysis showed the presence of a significant circadian rhythm of HF only in Group A with a peak in the early morning hours (phi at 03.45, % rhythm 50.0, p less than 0.03); a significant reduction of parasympathetic activation was also found in Group B (MSSD: 27.8 vs 15.4, p less than 0.05; pNN50: 2.9 vs 0.6, p less than 0.05). These results suggest a different pattern in circadian variation of HF and lower degree of time and frequency domain of heart rate variability, as a marker of vagal tone in patients with high susceptibility to coronary vasospasm.

[Characteristics of traditional Chinese medicine syndromes in both spontaneous and variant angina. An analysis of 21 cases]

An analysis of TCM syndromes is reported in 21 cases with both spontaneous and variant angina as compared with 147 cases with effort angina. The results showed that 3 characteristic features were present, which were as follows: the Biao-Shi syndrome of cold condensation was more than that of the control group in ratio of 42.86% to 3.40%; the Ben-Xu syndrome of Yang deficiency was more and that of Qi deficiency less than those in the control group, and they were in ratio of 33.33% to 6.12% and 33.33% to 72.11% respectively. An absolute reduction of blood supply resulted from coronary spontaneous spasm in both spontaneous and variant angina causes severe chest pain during attacks as a cold condensation type. Hyperfunction of parasympathetic nerves often occurring in coronary heart disease with Yang deficiency is liable to vasoconstriction of the large coronary arteries leading to episodes of both spontaneous and variant angina. The presence of less Qi deficiency type may be related to the less impairment of cardiac function resulted from the short course in these cases and only relatively mild state of an illness, even no marked lesion in coronary arteries in a part of patients with both spontaneous and variant angina. No significant difference in TCM syndromes occurred between spontaneous and variant angina. Both Yang and Yin deficiency, as the Ben-Xu syndromes, were more present in angina of cold condensation type.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prinzmetal angina and syncope]

Authors report an unusual case of variant angina associated with unconsciousness. They were able to prove by coronary angiography the vasospasm of the circumflexus artery which was responsible for the morning attacks of the 35 year old patient with unconsciousness, ST segment elevation and high degree AV block. Unconsciousness was the first and earliest sign of the coronary vasospasm.

[Reversible regional myocardial ischemia in variant angina]

A case of severe ventricular ischaemia induced by hyperventilation which occurred in a woman aged 44 years is presented. The ischaemia was confirmed by echocardiography and scintigraphy and coronary arteriography revealed spasm in the proximal segment of the anterior descending branch of the left coronary artery.

Angina pectoris due to possible vasospasm of small coronary arteries

Recently, the presence of vasospasm in small coronary arteries is speculated in animals and humans. A 40-year-old female patient complained of chest pain at rest. Left ventriculogram showed normal wall motions. Left and right coronary arteries were also normal. After methylergometrine maleate was selectively administered to a right coronary artery, she complained of chest pain, and ST-segment elevation was detected in leads II, III, and aVF of ECG. Right coronary arteriography was performed immediately, but no coronary stenosis was found. The next day, methylergometrine maleate was again administered intravenously and the patient complained of chest pain, but no ischemic changes were observed in ECG. Thallium-201 myocardial scintigraphy followed immediately. Apical perfusion defect was detected in stress image. In the delayed image, it showed complete redistribution. Three days later, catheterization and scintigraphy were performed at the same time. When methylergometrine maleate was administered to the left coronary artery, she complained of chest pain within a few minutes of the injection; however, ECG remained unchanged. 201Tl myocardial scintigraphy was performed immediately. In the stress image, it showed apical perfusion defect as shown in the intravenous methylergometrine maleate injection study. It also showed complete redistribution in the delayed image. Apical perfusion defect can be attributed to myocardial ischemia of left coronary artery, which are too small to be detected by conventional coronary arteriography. Vasospasm in small coronary arteries may be involved in this phenomenon.

[Coronary sinus blood thromboxane and prostacyclin in spontaneous myocardial ischemia]

The blood levels of 6-keto-PGE1 alpha and thromboxane B2 were measured in the coronary sinus of 15 males during and just after a spontaneous myocardial ischemic episode. The comparison was made in 30 males with coronary heart disease in the presence of exercise-induced angina in whom coronary sinus blood samples were taken during myocardial ischemia provoked by pacing and 6 males suffering from cardialgias without signs of coronary atherosclerosis. The patients with spontaneous anginal attacks had lower baseline 6-keto-PGE1 alpha (179.0 +/- 47.8 pkg/ml) than those with exercise-induced angina (336.0 +/- 65.7 pkg/ml; p less than 0.1). This difference became greater during ischemia (165.0 +/- 49.0 and 350.0 +/- 69.5 pkg/ml, respectively, p less than 0.05) and just after its elimination (166.0 +/- 48.7 and 413.0 +/- 76.0 pkg/ml, respectively, p less than 0.05). Coronary sinus blood thromboxane B2 levels were not substantially different in the presence or absence of myocardial ischemia. Thus, a decrease in the prostacyclin-forming function of the coronary endothelium plays a definite role in the genesis of spontaneous myocardial ischemic episodes.

Usefulness of intracoronary injection of acetylcholine as a provocative test for coronary artery spasm in patients with vasospastic angina

In order to examine both the sensitivity and specificity of coronary artery spasm induced by intracoronary injection of acetylcholine in patients with vasospastic angina, incremental doses of acetylcholine (20, 30, and 50 micrograms) were injected directly into each coronary artery in 21 patients with variant angina (group A), in 28 patients with other types of vasospastic angina (group B), and in 20 patients without any significant coronary artery disease (group C). Coronary artery spasm was defined as severe vasoconstriction (greater than or equal to 90% of reduction in luminal diameter) with chest pain and/or ischemic changes in the electrocardiogram. Intracoronary injection of acetylcholine induced spasm of at least one coronary artery in 20 patients (95%) of group A, in 27 patients (96%) of group B, and in only 2 patients (10%) of group C. The low dose of acetylcholine (20 micrograms) induced coronary spasm more frequently in group A patients (81%) than in group B patients (43%) (P less than 0.05). ST-segment elevation associated with anginal attacks was significantly (P less than 0.05) more frequent in group A (71%) than in group B (39%). When acetylcholine was injected separately into the left and right coronary arteries, spasm of both coronary arteries was observed in 7 out of 14 of group A (50%), in 8 out of 22 of group B (36%), and in none of the 20 of group C. We concluded that intracoronary injection of acetylcholine is a sensitive and reliable method for the induction of coronary spasm in patients with vasospastic angina as well as in those with variant angina.

Effect of direct intracoronary administration of methylergonovine in patients with and without variant angina

The effects of intracoronary administration of methylergonovine were studied in 21 patients with variant angina and 22 patients with atypical chest pain and in others without angina pectoris (control group). Methylergonovine was administered continuously at a rate of 10 micrograms/min up to 50 micrograms. In all patients with variant angina, coronary spasm was provoked at a mean dose of 28 +/- 13 micrograms (mean +/- SD). In the control group neither ischemic ST change nor localized spasm occurred. The basal tone of the right coronary artery was significantly lower than that of the left coronary artery. The percentage of vasoconstriction of the right coronary artery was significantly higher than that of the left coronary artery. These results suggest that spasm provocation tests, which use an intracoronary injection of a relatively low dose of methylergonovine, have a high sensitivity in variant angina and the vasoreactivity of the right coronary artery may be greater than that of the other coronary arteries.

Evaluation of a newly devised three-lead Holter recording during treadmill testing in the diagnosis of ischemic ST changes

Sixty-five patients (54 men, 11 women) with angina pectoris were studied using a technique for recording a 3-lead electrocardiogram without increasing the number of channels and electrodes in the commercial 2-channel Holter recorder. In 52 of the 65 patients, simultaneous ECGs with both the 3-lead Holter method and the conventional 12-lead system during treadmill exercise testing were performed. The results of the two systems in detecting significant ST depressions were consistent in 51 of 52 patients (98%). Twenty-seven of the 32 patients with significant coronary stenosis showed ST depressions during exercise both in the 3-lead Holter and the 12-lead ECG systems. There were cases in which ST depressions were confined only to the CM2 lead (n = 1), the CM5 lead (n = 18) or the CMf lead (n = 3). This indicates that at least three leads are needed in the Holter system for the detection of certain ST changes. The sensitivity of the Holter system during exercise in detecting significant coronary artery disease was the same as that of the 12-lead system (84%). Two of the total 65 patients had variant angina at night. No ST changes in the CM5 lead were observed in either case. Thus, the 3-lead Holter monitoring technique is as accurate as the 12-lead system for the detection of ischemic ST depressions associated with coronary stenosis and is unlikely no miss the signs of variant angina. In addition, this technique is expandable since it can continuously switch between leads using the same channel.

William Heberden and Myron Prinzmetal: angina pectoris

The most significant accounts of angina pectoris appeared in the medical literature separated by nearly two centuries. They were Heberden's initial description of classic angina and Prinzmetal's report of the variant form. Angina pectoris represents a transient myocardial oxygen deficiency. It is usually related to atherosclerotic coronary artery disease, but there are a number of less common etiologies, most notably aortic stenosis. Stable and unstable forms exist, with stable angina being further subclassified as being of one of four patterns: classic, variant, atypical, and angina equivalent.

[Variant (Prinzmetal's) angina with diffuse coronary spasm without coronary sclerosis]

A 49-year-old man developed, over a period of three years, progressively more frequent nocturnal attacks of angina and palpitations. Exercise electrocardiogram was negative. 24-hour Holter monitoring revealed ventricular extrasystoles and tachycardia with ST segment elevations. The dominant left coronary artery, which was free of atherotic changes, went into diffuse spasm after ergonovine administration, accompanied by angina and ventricular extrasystoles. Registration of spontaneous ischaemia confirmed the diagnosis of variant (Prinzmetal) angina. Administration of twice daily 90 mg diltiazem retard and once daily 120 mg isosorbide dinitrate retard at night ended the spasms and with it the attacks of angina and the arrhythmias. This case illustrates that typical angina and ventricular tachyarrhythmias can be caused by spontaneous coronary spasms, even in the presence of normal exercise ECGs and coronary angiograms. If coronary artery spasms are not detectable by ECG, the ergonovine test may further the diagnosis.

[Various clinical and vasomotor coronary responses to calcium block in mixed angina and Prinzmetal's angina, expression of various physiopathologic mechanisms]

Impedance to flow due to coronary spasm is currently interpreted as the mechanism of Prinzmetal angina. Flow impedance, probably of vasomotor origin, superimposed on severe coronary stenosis is also viewed as the trigger for the spontaneous component of mixed angina. The major question that we attempted to answer in this study was whether mixed angina may be considered a variant of the Prinzmetal form, or a particular manifestation of the classic effort form. For these purposes we investigated the acute vasomotor response to calcium channel blockade (nifedipine 10 mg sl) of both significant (greater than 50%) stenotic lesions and of normal coronary vessels in 22 patients with mixed angina and in 14 patients with Prinzmetal angina, and correlated it with the clinical response to treatment (nifedipine 20 mg qid). Calcium channel blockade, in fact, is considered as a specific remedy in the presence of an altered coronary vasomotility. The clinical response was evaluated through ambulatory Holter monitorings of 48 hour duration, while on placebo, nifedipine and placebo again. In mixed angina an angiographic evaluation showed that the residual lumen diameter of significant lesions was unchanged in 2, enhanced in 11 and reduced in 9 patients after sl nifedipine; lumen variations from base line ranged from +1.5 to -1.3 mm. Acute stenosis widening or narrowing correlated closely with the efficacy or not of the treatment. In the Prinzmetal group the vast majority of the lesions had compliant portions which invariably responded with dilatation (the residual coronary lumen increased by an average of 69% of base line); 100% of patients in this group responded favourably to treatment.(ABSTRACT TRUNCATED AT 250 WORDS)