Comparison of the risk factors for coronary artery spasm with those for organic stenosis in a Japanese population: role of cigarette smoking

Clinical features and prognosis of patients with coronary spasm-induced non-ST-segment elevation acute coronary syndrome

BACKGROUND

The prevalence, clinical features, and long-term outcome of patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS) associated with coronary spasm are not fully investigated.

METHODS AND RESULTS

This observational multicenter study enrolled 1601 consecutive patients with suspected NSTE-ACS who underwent cardiac catheterization between January 2001 and December 2010. A culprit lesion was found in 1152 (72%) patients. In patients without a culprit lesion, the acetylcholine provocation test was performed in 221 patients and was positive in 175 patients. In the other patients, coronary spasm was verified in 145 patients during spontaneous attack. Spasm-induced NSTE-ACS was diagnosed in 320 (20%) patients. Multivariable analysis identified age <70 years (odds ratio [OR] 2.19, 95% CI 1.58 to 3.04), estimated glomerular filtration rate >60 mL/min per 1.73 m(2) (OR 1.72, 95% CI 1.16 to 2.56), and lack of hypertension (OR 2.55, 95% CI 1.90 to 3.41), dyslipidemia (OR 2.76, 95% CI 2.05 to 3.73), diabetes mellitus (OR 2.49, 95% CI 1.78 to 3.48), previous myocardial infarction (OR 5.37, 95% CI 2.89 to 10.0), and elevated cardiac biomarkers (OR 2.84, 95% CI 2.11 to 3.83) as significant correlates of spasm-induced NSTE-ACS (P<0.01 for all variables). Transient ST-segment elevation during spontaneous attack (variant angina) was observed in 119 patients with spasm-induced NSTE-ACS. Variant angina was more common in nondyslipidemic men among patients with spasm-induced NSTE-ACS.

CONCLUSIONS

The study showed frequent involvement of coronary spasm in the pathogenesis of NSTE-ACS. Variant angina was observed in one third of patients with spasm-induced NSTE-ACS. Coronary spasm should be considered even in patients with less coronary risk factors and nonobstructive coronary arteries.

Coronary artery spasm: review and update

Coronary artery spasm (CAS), an intense vasoconstriction of coronary arteries that causes total or subtotal vessel occlusion, plays an important role in myocardial ischemic syndromes including stable and unstable angina, acute myocardial infarction, and sudden cardiac death. Coronary angiography and provocative testing usually is required to establish a definitive diagnosis. While the mechanisms underlying the development of CAS are still poorly understood, CAS appears to be a multifactorial disease but is not associated with the traditional risk factors for coronary artery disease. The diagnosis of CAS has important therapeutic implications, as calcium antagonists, not β-blockers, are the cornerstone of medical treatment. The prognosis is generally considered benign; however, recurrent episodes of angina are frequently observed. We provide a review of the literature and summarize the current state of knowledge regarding the pathogenesis of CAS.

A series of unfortunate events: prinzmetal angina culminating in transmural infarction in the setting of acute gastrointestinal hemorrhage

Prinzmetal angina or vasospastic angina is a clinical phenomenon that is often transient and self-resolving. Clinically it is associated with ST elevations on the electrocardiogram, and initially it may be difficult to differentiate from an acute myocardial infarction. The vasospasm induced in this setting occurs in normal or mildly to moderately diseased vessels and can be triggered by a number of etiologies including smoking, changes in autonomic activity, or drug ingestion. While the ischemia induced is usually transient, myocardial infarction and life-threatening arrhythmias can occur in 25% of cases. We present the case of a 65-year-old female where repetitive intermittent coronary vasospasm culminated in transmural infarction in the setting of gastrointestinal bleeding. This case highlights the mortality associated with prinzmetal angina and the importance of recognizing the underlying etiology.

[Severe coronary vasospasm]

A 50-year-old man, with chronic kidney disease and on dialysis, underwent coronary angiography in the context of acute coronary syndrome, which revealed focal lesions (type A) in the proximal left anterior descending and mid circumflex arteries. Ad-hoc angioplasty was performed on both lesions with direct stenting. An immediate drop in arterial blood pressure was observed and the angiogram showed new lesions with reduced flow throughout the coronary tree, progressing to cardiogenic shock and electromechanical dissociation. During cardiopulmonary resuscitation maneuvers, intracoronary verapamil was administered and TIMI 3 flow, sinus rhythm and a rise in blood pressure were obtained. Clinical stability was progressively restored. The patient was discharged medicated with calcium channel blockers and nitrates. During follow-up, he was twice readmitted for unstable angina. Coronary angiography revealed findings that could easily have been interpreted as new obstructive lesions, but these resolved after administration of intracoronary nitrates.

Low glomerular filtration rate is associated with high prevalence of vasospastic angina

BACKGROUND

Although chronic kidney disease is associated with a high prevalence of cardiovascular disease, the relationship between coronary artery spasm and renal dysfunction has not been elucidated.

METHODS AND RESULTS

We evaluated 139 patients with chest pain at rest who had no significant organic stenosis on coronary angiograms and who underwent coronary spasm provocation tests using acetylcholine or ergonovine. The results of the provocation tests revealed that 59 patients had vasospastic angina (VSA), and that 80 did not (non-VSA). We analyzed the association between VSA and renal dysfunction using the estimated glomerular filtration rate (eGFR). The eGFR was significantly lower in the VSA group than in the non-VSA group (P = 0.013). The patients were assigned to quartiles (Q) 1, 2, 3 and 4 based on eGFR (ml·min⁻¹·1.73 m²) < 64.1, 64.1-74.7, 74.8-85.0 and ≥ 85.1, respectively, in each of which the prevalence of VSA was 57%, 53%, 34% and 26%, respectively. The prevalence of VSA was significantly higher in Q1 than in Q4 (P = 0.008). Logistic regression analysis showed that the independent factors associated with the presence of VSA were a lower eGFR (P = 0.011) and male gender (P = 0.001).

CONCLUSIONS

Lower levels of eGFR in our study population were significantly and independently associated with a high prevalence of VSA, suggesting that a lower eGFR could be a risk factor for VSA.

Impact of chronic kidney disease on the severity of initially diagnosed coronary artery disease and the patient prognosis in the Japanese population

This study evaluated the relationship between the severity of coronary artery disease (CAD) and traditional coronary risk factors, metabolic syndrome, and chronic kidney disease (CKD). Three hundred and forty-three patients (35-90 years of age) with initial diagnosis of CAD were separated into two groups: 165 patients with single-vessel coronary artery disease (SVD group) and 178 patients with multivessel coronary artery disease (MVD group). We compared the risk factors for CAD between the two groups. An adjusted multivariate analysis showed that only CKD was associated with MVD (odds ratio, 2.85; 95% confidence interval [CI], 1.76-4.63; P = 0.00002). Next, the relationship between the severity of CAD, CKD, and the incidence of subsequent major adverse cardiac event (MACE) was investigated in 338 patients during the patient follow-up. The risk of MACE was approximately threefold higher in the group with MVD and CKD stage of 3 or greater than in the group with SVD but without CKD stage of 3 or greater (adjusted hazard ratio, 3.40; 95% CI, 1.26-9.17; P = 0.016). A statistical analysis also suggested that having MVD and advanced CKD was a more powerful risk factor for MACE. The comparison of risk factors between patients with SVD and patients with MVD revealed that CKD was the most important risk factor for MVD. In addition, having MVD and advanced CKD together was a crucial risk factor for subsequent MACE. To reduce the progression of CAD and to improve the prognosis of patients with MVD, the renal status should therefore be carefully assessed during treatment for CAD.

Gender differences among korean patients with coronary spasm

BACKGROUND AND OBJECTIVES

The gender differences among Korean patients with coronary spasm have not been defined. We thus determined the gender differences among Korean patients with coronary spasm.

SUBJECTS AND METHODS

Patients with chest pain and/or syncope who were admitted to Kyungpook National University Hospital between January 2001 and August 2008 were included. Provocation of coronary vasospasm with intracoronary ergonovine maleate was performed when baseline coronary angiography showed no significant stenosis or there was a strong clinical suspicion of coronary spasm. The clinical characteristics were analyzed from 104 consecutive patients (56+/-9 years of age; 21 females) who were diagnosed with coronary spasm.

RESULTS

Female patients were younger (52+/-7 vs. 57+/-10 years, p=0.046) with lower rates of smoking and alcohol consumption histories than male patients (19% vs. 65%, p<0.001; and 43% vs. 89%, p<0.001, respectively). The other clinical characteristics were not significantly different, except for the triglyceride levels.

CONCLUSION

The majority of patients with coronary spasm were males who were smokers and alcohol consumers. The female patients had lower rates of smoking and alcohol consumption, and they were younger than the male patients. Further studies are needed to investigate the relevance of gender differences in the pathogenesis of coronary spasm.

Impact of hypertension on coronary artery spasm as assessed with intracoronary acetylcholine provocation test

Both hypertension and coronary artery spasm (CAS) are associated with endothelial dysfunction. Thus, a higher incidence of CAS is expected in hypertensive patients. We evaluated the impact of hypertension on CAS with intracoronary acetylcholine (ACh) provocation test. A total of 986 patients (685 hypertensive patients vs 301 normotensive patients) who underwent coronary angiography with ACh provocation test were enrolled. ACh was injected into the left coronary artery in incremental doses of 20, 50 and 100 microg min(-1). Significant CAS was defined as a transient >70% luminal narrowing with concurrent chest pain and/or ST-segment changes. Although the incidences of significant ACh-induced CAS were similar between hypertensive and normotensive patients (35.8 vs 39.2%, P=0.303), multivariate logistic analysis showed that hypertension was negatively associated with ACh-induced CAS (odds ratio: 0.70, 95% confidence interval: 0.51-0.94, P=0.020). The angiographic characteristics of ACh-induced CAS were similar between these two groups. Subgroup analysis regarding the impact of the status of blood pressure control on CAS showed that hypertensive patients with controlled blood pressure had a significantly higher incidence of CAS than those with uncontrolled blood pressure (45.2 vs 27.9%, P<0.001), and that uncontrolled blood pressure was negatively associated with ACh-induced CAS (odds ratio: 0.56, 95% confidence interval: 0.40-0.79, P=0.001). In conclusion, despite the expected endothelial dysfunction, hypertension and uncontrolled blood pressure are negatively associated with CAS, suggesting that the mechanisms and risk factors of CAS may be significantly different from those of coronary artery disease.

Coronary spasm preferentially occurs at branch points: an angiographic comparison with atherosclerotic plaque

BACKGROUND

Coronary spasm plays an important role in the pathogenesis of ischemic heart disease. However, similarities and differences between coronary spasm and atherosclerosis are not known. We examined the angiographic characteristics of coronary spasm in comparison with those of atherosclerosis.

METHODS AND RESULTS

Thirty-two left anterior descending arteries, 11 left circumflex arteries, and 23 right coronary arteries with spasm and atherosclerotic plaque were analyzed for the localization of spasm in comparison with that of plaque in 47 patients (38 men and 9 women, mean age 66.8+/-10.3 yrs). Spasm predominantly occurred at the branch point as compared with plaque in each of the 3 arteries (76.7% versus 23.3%, P<0.0001; 72.7% versus 9.1%, P<0.039; and 60.0% versus 10.0%, P=0.002, in the left anterior descending, left circumflex, and right coronary arteries, respectively). Spasm involved the proximal segment less frequently as compared with plaque in each of the 3 arteries (56.7% versus 93.3%, P<0.0001; 18.2% versus 81.8%, P=0.016; and 15.0% versus 75.0%, P<0.0001 in the left anterior descending, left circumflex, and right coronary arteries, respectively). Most spasms occurred at the nonplaque site in each of the 3 arteries (73.3%, P=0.018; 100%, P<0.0001; and 75.0%, P=0.041 in the left anterior descending, left circumflex, and right coronary arteries, respectively).

CONCLUSIONS

Coronary spasm preferentially occurred at branch points and nonplaque sites, whereas the atherosclerotic lesion was predominantly localized at the nonbranch points of the curved proximal segments. Coronary spasm may thus be a manifestation of a distinct type of arteriosclerosis different from the lipid-laden coronary atherosclerosis.

Effects of a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, fluvastatin, on coronary spasm after withdrawal of calcium-channel blockers

OBJECTIVES

The purpose of this study was to determine whether a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) suppresses coronary spasm.

BACKGROUND

Coronary spasm is associated with endothelial dysfunction. Statins have been shown to improve endothelial function.

METHODS

This was a prospective, randomized, open-label, end point study. Sixty-four patients who had no significant organic coronary stenosis and in whom coronary spasm was induced by intracoronary injection of acetylcholine (ACh) were randomly assigned to fluvastatin 30 mg/day plus the conventional calcium-channel blocker (CCB) therapy (31 patients, statin group) or the conventional CCB therapy (33 patients, nonstatin group). After 6 months of treatment, the intracoronary injection of ACh was repeated and the coronary spasm was assessed.

RESULTS

Coronary spasm was suppressed in 16 of the 31 patients (51.5%, p < 0.0001) of the statin group and in 7 of the 33 patients (21.2%, p = 0.0110) of the nonstatin group after 6 months of treatment. Thus, the number of patients with ACh-induced coronary spasm was significantly reduced in the statin group as compared with the nonstatin group (51.6% vs. 21.2%, p = 0.0231) after 6 months of treatment.

CONCLUSIONS

The addition of fluvastatin 30 mg/day to the conventional CCB therapy for 6 months significantly reduced the number of patients with ACh-induced coronary spasm as compared with the conventional CCB therapy. Thus, a statin (fluvastatin) may possibly be a novel therapeutic drug for coronary spasm.

Coronary artery spasm--clinical features, diagnosis, pathogenesis, and treatment

Coronary (artery) spasm plays an important role in the pathogenesis of ischemic heart disease, including stable angina, unstable angina, myocardial infarction, and sudden death. The prevalence of coronary spasm differs among populations, is higher in Japan and Korea than in the Western countries probably due to genetic as well as environmental factors. Coronary spasm occurs most often from midnight to early morning and is usually not induced by exercise in the daytime. The attacks of coronary spasm are associated with either ST segment elevation or depression, or negative U wave on ECG. Patients with multi-vessel coronary spasm may suffer from lethal arrhythmia, including advanced AV block, ventricular tachycardia or fibrillation, or even sudden death, and they are often resistant to conventional medical therapy including Ca-channel blockers (CCBs). Endothelial nitric oxide (NO) activity is reduced and markers of oxidative stress are elevated in patients with coronary spasm. Thrombogenesis is enhanced and plasma levels of hsCRP and P-selection are elevated in patients with coronary spasm. Thus, patients with coronary spasm have endothelial dysfunction and are suffering from a low-grade chronic inflammation. Polymorphisms of endothelial NO synthase, smoking, and low-grade inflammation are the most important risk factors for coronary spasm. Coronary spasm is a hyper-contraction of coronary smooth muscle triggered by an increase of intracellular Ca2+ in the presence of an increased Ca2+ sensitivity. It has been shown that RhoA/ROCK pathway is involved in Ca2+ sensitivity and that the reduced endothelial NO activity results in increased Ca2+ sensitivity through enhanced RhoA/ROCK pathway. Accordingly, it is possible that in addition to CCBs, RhoA/ROCK pathway blockers may prove to be useful for the treatment of coronary spasm.

Coronary Spasm is Associated With Chronic Low-Grade Inflammation

BACKGROUND

Coronary spasm plays an important role in the pathogenesis of ischemic heart disease and it may be associated with low-grade inflammation.

METHODS AND RESULTS

Intracoronary injection of acetylcholine was done in 199 patients (99 men, 100 women, mean age, 64.5+/-11.0 years) with chest pain and normal coronary angiograms. According to the results of the provocation test, the study subjects were divided into 2 groups: the spasm group of 112 patients and the non-spasm group of 87 patients. Clinical data including high-sensitivity C-reactive protein (hs-CRP) and other coronary risk factors were compared between the 2 groups. Serum levels of hs-CRP were significantly higher in the spasm group than in the non-spasm group (median: 1.2 mg/L vs 0.5 mg/L, p<0.005). Multivariate analysis showed that hs-CRP and smoking history were independently associated with coronary spasm with an odds ratio of 2.28 (p=0.027) and 2.25 (p=0.037), respectively, with a hs-CRP value of > or = 2 mg/L as cutoff point.

CONCLUSIONS

Minor elevations of the serum hs-CRP level are significantly associated with coronary spasm, suggesting that chronic low-grade inflammation may be involved in the pathogenesis of coronary spasm.

Low-Grade Inflammation, Thrombogenicity, and Atherogenic Lipid Profile in Cigarette Smokers

BACKGROUND

Cigarette smoking is one of the major risk factors for atherosclerotic coronary disease, but the precise mechanism(s) by which cigarette smoking promotes atherosclerosis remains unknown. As there is now increasing evidence that atherosclerosis is an inflammatory condition, the present study investigated whether inflammation exists in smokers.

METHODS AND RESULTS

The inflammatory markers and lipid profiles were compared among a current-smoker group (210 patients, mean age 61.8 +/- 11.0 years), past-smoker group (115 patients, 67.1 +/- 9.0 years) and never-smoked group (113 patients, 68.2 +/- 10.7 years), all of whom had no apparent signs of inflammation. The respective levels of blood leukocytes, platelets, C-reactive protein and fibrinogen were significantly higher in current-smokers than in the never-smoked group (6,600 +/- 1,723 /microl vs 5,638 +/- 1,313 /microl p<0.01; 22.7 +/- 6.8 x 10(4) /microl vs 18.7 +/- 7.4 x 10(4) /microl, p<0.01; 3.50+/-4.91 mg/L vs 1.92+/-3.02 mg/L, p<0.01; 334.2 +/- 90.9 mg/dl vs 314.7 +/- 80.2 mg/dl, p<0.05). The respective levels of plasma triglycerides, remnant-like particle cholesterol and apolipoprotein-B were significantly higher and that of high-density lipoprotein cholesterol significantly lower in the current-smokers than in the never-smoked group (152.4 +/- 96.2 mg/dl vs 120.5 +/- 58.1 mg/dl, p<0.01; 5.4+/-6.3 mg/dl vs 3.8 +/- 2.0 mg/dl, p<0.05; 101.6 +/- 23.7 mg/dl vs 95.0 +/- 21.2 mg/dl, p<0.05; 45.2 +/- 12.3 mg/dl vs 50.6 +/- 15.6 mg/dl, p<0.01). Past smokers had intermediate values between those of current-smokers and never-smoked.

CONCLUSIONS

Low-grade inflammation, atherogenic dyslipidemia, and hypercoagulability are present in smokers compared with those who have never smoked among subjects without apparent inflammation who underwent coronary angiography on suspicion of coronary artery disease.

Hypoadiponectinemia is associated with coronary artery spasm in men

BACKGROUND

The relationship between adiponectin and coronary spastic angina (CSA), both of which are closely involved in coronary endothelial dysfunction, has not been elucidated.

METHODS AND RESULTS

Plasma adiponectin concentrations were examined in 55 men with CSA and 55 with chest pain syndrome (CPS). The plasma log-adiponectin levels were significantly lower in patients with CSA than with CPS (0.61+/-0.28 vs 0.80+/-0.21 microg/ml, p < 0.0001). The prevalence of smoking was significantly higher in the CSA patients than in those with CPS (50.9% vs 29.1%, p = 0.0195). In multiple logistic regression analysis, log-adiponectin (p = 0.0008) and smoking (p = 0.0210) were independent determinants of CSA. Conclusions Hypoadiponectinemia is a potential risk factor for CSA in men, independent of smoking.

Increased plasma levels of thioredoxin in patients with coronary spastic angina

To determine whether plasma levels of thioredoxin are associated with coronary spasm, we measured the plasma levels of thioredoxin in 170 patients who had <25% organic stenosis in coronary arteriography. According to the results of cardiac catheterization, we divided the patients into two groups: a coronary spastic angina group (n=84) and a chest pain syndrome group (n=86). The plasma levels of thioredoxin were significantly higher in the coronary spastic angina group than in the chest pain syndrome group (40.7 +/- 4.1 versus 18.2 +/- 1.1 ng/ml, p<0.0001). Furthermore, the increased plasma levels of thioredoxin were associated with high disease activity indicated by the frequency of angina attacks (p=0.0004). In multiple logistic regression analysis, the higher levels of thioredoxin [relative risk 14.8, 95% confidence interval (5.13-42.9), p<0.0001] and current smoking [relative risk 3.39, 95% confidence interval (1.31-8.75), p=0.012] were significant and independent variables associated with coronary spasm. We demonstrated that the plasma levels of thioredoxin were increased in the coronary spastic angina group, and increased levels of thioredoxin were associated with high disease activity. The plasma levels of thioredoxin and current smoking were risk factors for coronary spastic angina, and they were independent from other traditional risk factors.

Synergistic interaction of T???786???C polymorphism in the endothelial nitric oxide synthase gene and smoking for an enhanced risk for coronary spasm

OBJECTIVE

We previously reported that a T-786-->C polymorphism in the 5'-flanking region of the endothelial nitric oxide synthase gene and smoking were independently associated with coronary spasm; however, the interaction between this polymorphism and smoking remains to be elucidated.

METHODS

We analyzed 209 men and 238 women who were admitted consecutively at our institution; all subjects received an intracoronary injection of acetylcholine (ACh) while undergoing coronary angiography for evaluation of chest pain: all subjects had no significant coronary stenosis. We divided these subjects into four groups: non-smokers with T/T genotype (Control Group A); non-smokers with C/T or C/C genotype (Group B); smokers with T/T genotype (Group C); and smokers with C/T or C/C genotype (Group D). We further examined quantitative coronary angiographies of the left anterior descending coronary artery in a subset of 54 consecutive men and 53 consecutive women.

RESULTS

The frequencies of coronary spasm in Group B (male: 61%, female: 78%), Group C (62%, 59%) and Group D (91%, 92%) were significantly higher than in Group A (30%, 38%). In the males, ACh-induced vasoconstriction was greatest in Group D, and the change was weakest in Group A. In the females, ACh-induced vasoconstrictions were significantly greater in Groups B, C and D than in Group A. The T-786-->C polymorphism and smoking combine to increase the risk of coronary spasm.

Glutathione attenuates coronary constriction to acetylcholine in patients with coronary spastic angina

This study examined the effect of reduced glutathione (GSH), an important antioxidant that restores intracellular redox imbalance and prevents inactivation of endothelial-derived nitric oxide, on the abnormal vasomotor reactivity in spastic coronary arteries. The responses of epicardial diameter of the left coronary arteries to intracoronary infusion of acetylcholine (ACh; 50 microg/min) were measured by quantitative coronary angiography before and during combined intracoronary infusion of GSH (50 mg/min for 6 min) or saline as a placebo in 24 patients with coronary spastic angina and in 28 control patients. All of the spastic coronary arteries showed constrictor response to ACh, whereas the control coronary arteries as a whole showed only minimal diameter changes to ACh. GSH infusion suppressed constrictor response of epicardial diameter to ACh in patients with coronary spastic angina, whereas it had no significant effect in control subjects. Saline infusion did not have any effects. The results indicate that GSH attenuated the constrictor response to ACh in epicardial coronary arteries of patients with coronary spastic angina. GSH may have an important role in the regulation of coronary vasomotor function in patients with coronary spastic angina.