Insights into the invasive diagnostic challenges of coronary artery vasospasm - A systematic review

Coronary provocation testing is an essential diagnostic procedure when evaluating vasospastic angina. Invasive methods using acetylcholine or ergonovine are considered the current gold standard. Despite efforts from global cardiovascular institutions, current protocols vary in dosage, administration time, and procedural approach. In addition, concerns over the specificity of findings and potential complications have limited routine uptake of this procedure in clinical practice. This systematic review evaluates current diagnostic protocols, focusing on invasive provocation testing. We included studies using intracoronary provocation testing with acetylcholine or ergonovine for the assessment of coronary artery vasospasm that detailed specific elements of the procedure (dosage, administration time, etc.) and included ≥50 patients. A total of 28 articles met strict inclusion criteria. Our review highlights the heterogeneity between current diagnostic protocols for invasive provocation testing. We believe standardization of a diagnostic protocol will encourage both current and future cardiologists to incorporate such procedures in the evaluation of variant angina.

Post-spastic flow recovery time to document vasospasm induced ischemia during acetylcholine provocation testing

Background

Intracoronary acetylcholine (ACh) provocation is an established method for diagnosing epicardial and microvascular vasospasm in contemporary clinical practice. We hypothesize that ACh-induced vasospasm is followed by post-spastic reactive hyperemia (PSRH), which is measured as an increased flow-recovery time.

Objectives

To assess flow-recovery time, indicative of ischemia, among the diagnostic endotypes that follow ACh provocation testing.

Methods

Patients with angina and non-obstructive coronary artery disease on angiography who underwent ACh provocation testing were included in this analysis. Doppler flow was continuously measured during the procedure and used to determine the flow-recovery time, which was calculated as time between cessation of ACh infusion and the point of flow recovery.

Results

Conventional provocation testing according to the COVADIS criteria diagnosed vasospasm in 63%(77/123), an equivocal result in 22%(27/123) and a negative result in 15%(19/123) of patients. In reaction to the highest-dose of ACh, flow-recovery time was significantly extended and similar in the epicardial, microvascular and equivocal test results compared to the negative result (all p < 0.001) indicative of PSRH.

Conclusion

Flow-recovery time in patients with an equivocal result is similar to patients with vasospasm, which indicates the occurrence of myocardial ischemia and therefore, these patients may benefit from medical treatment.

Coronary vasospasm: A narrative review

Coronary artery vasospasm (CAVS) plays an important role in acute chest pain syndrome caused by transient and partial or complete occlusion of the coronary arteries. Pathophysiology of the disease remains incompletely understood, with autonomic and endothelial dysfunction thought to play an important role. Due to the dynamic nature of the disease, its exact prevalence is not entirely clear but is found to be more prevalent in East Asian and female population. Cigarette smoking remains a prominent risk factor, although CAVS does not follow traditional coronary artery disease risk factors. Many triggers continue to be identified, with recent findings identifying chemotherapeutics, allergens, and inflammatory mediators as playing some role in the exacerbation of CAVS. Provocative testing with direct visualization is currently the gold-standard for diagnosis, but non-invasive tests, including the use of biomarkers, are being increasingly studied to aid in the diagnosis. Treatment of the CAVS is an area of active research. Apart from risk factor modification, calcium channel blockers are currently the first line treatment, with nitrates playing an important adjunct role. High-risk patients with life-threatening complications should be considered for implantable cardioverter defibrillator (ICD), although timing criteria for escalated therapy require further investigation. The role of pharmaceuticals targeting oxidative stress remains incompletely understood.

Diffuse coronary artery vasospasm in a patient with subarachnoid hemorrhage: A case report

BACKGROUND

Coronary artery vasospasm (CAV) is a reversible, transient form of vasoconstriction with clinical manifestations ranging from stable angina to acute coronary syndromes (ACS). Vasospasm of epicardial coronary arteries or associated micro-vasculature can lead to total or subtotal occlusion and has been demonstrated in nearly 50% of patients undergoing angiography for suspected ACS. The mechanism for CAV has been described in literature, but in a subgroup of patients presenting with intracranial hemorrhage, it appears to be multifactorial. These patients tend to have electrocardiographic changes, elevation of cardiac biomarkers of injury and neurogenic stress cardiomyopathy.

CASE SUMMARY

A 44-year-old woman presented with severe headaches and tonic-clonic seizures. She was found to have diffuse subarachnoid hemorrhage (SAH) requiring ventricular drain placement, coil embolization and induced hypertension. She subsequently developed chest pain with ST elevations in anterior precordial leads, elevated cardiac enzymes and apical ballooning with left ventricular ejection fraction of 35% on transthoracic echocardiogram. Coronary angiogram revealed severe diffuse triple vessel stenoses secondary to CAV seen distally. Subsequent cardiac MRI notable for apical non-viability and scar formation.

CONCLUSION

This case highlights a unique etiology of acute myocardial infarction in a patient with SAH leading to ST elevations, diffuse triple vessel CAV and apical scar.

Recurrent Coronary Artery Vasospasm in a Patient with Hepatocellular Carcinoma Treated with Sorafenib: a Case Report and Literature Review

Tyrosine kinase inhibitors are widely used as targeted treatments for various malignancies. Sorafenib is an orally active tyrosine kinase inhibitor that blocks the signaling pathways of several growth factors. Its use is approved for various malignancies such as unresectable hepatocellular carcinoma, renal cell carcinoma, and gastrointestinal stromal tumors. Several adverse effects have been reported in the literature; however, cardiotoxicity is rare. We present a case of recurrent coronary vasospasm caused by short-term administration (5 days) of sorafenib. Since it caused refractory ischemia after re-administration, we had no choice but to stop the treatment.

Acute ST Elevation Myocardial Infarction Due to Allergic Reaction, Kounis Syndrome

Kounis syndrome is defined by the occurrence of an acute coronary syndrome (ACS) in the setting of an allergic, hypersensitivity or anaphylactic condition. Degranulation of mast cells and platelet activation leading to the release of multiple inflammatory mediators are thought to make the arterial circulation susceptible to acute cardiac events. It is an often underdiagnosed entity in the emergency setting, due to lack of awareness among emergency providers. Identifying Kounis syndrome is critical, since managing ACS differs from that of a classical acute myocardial infarction. We present the case of a 72-year old male patient with a history of stable coronary disease who presented to the emergency department with a diffuse pruritic rash and chest pain. Electrocardiogram showed ST elevation myocardial infarction. Urgent coronary angiography revealed total occlusion of the mid left anterior descending coronary artery which was treated with a drug eluting stent with an excellent outcome. The pruritic rash responded to treatment with intravenous corticosteroids and antihistamines; No allergens were identified. The patient's symptoms resolved and he had an uneventful hospitalization. The diagnosis of Kounis syndrome can complicate the management of acute allergic reactions. Special precautions should be taken by emergency physicians with regards to the administration of beta blockers, morphine and vasodilators, which may be detrimental in this setting.

A silent myocardial infarction with normal coronary arteries associated with Graves' disease

Acute myocardial infarction (AMI) is a scarce but fatal complication in Graves' disease (GD). Silent myocardial infarction (MI) associated with GD has never been reported. A 37-year-old male patient was admitted due to poorly controlled hyperthyroidism and persistent fever. But the patient did not complain of chest pain on admission. The electrocardiogram (ECG) showed Q waves and ST-segment elevations. Cardiac troponin I (cTnI) was sharply increased. He was qualified to an emergency coronary angiography which showed normal coronary arteries without any stenosis. The potential mechanisms for AMI with angiographically normal coronary arteries in the setting of hyperthyroidism may be attributed to the hyper-metabolic state due to thyrotoxicosis, severe vasospasm in coronary artery, coagulation abnormalities, and the inflammatory/autoimmune milieu. In conclusion, patients with GD-associated silent MI are unusual. Early recognition and diagnosis by clinicians provide a better prognosis. This case demonstrates the importance of ECG and cTnI screening among GD patients.

Relief of vasospasm with fasudil after off-pump coronary artery bypass grafting: a case study

Background

Coronary vasospasm after coronary artery bypass grafting (CABG) is a rare but potentially lethal complication. It is often refractory to several vasodilators. We report a case of refractory coronary vasospasm relieved by fasudil injection.

Case presentation

A 74-year-old woman who had three instances of in-stent stenosis at the left anterior descending artery (LAD) was referred for CABG treatment. Preoperative coronary angiography showed 90% in-stent stenosis of the proximal LAD and 75% stenosis of the diagonal branch. We performed a left internal thoracic artery (LITA)-LAD bypass and a right internal thoracic artery (RITA) diagonal branch bypass. After anastomosis, transit time flow measurement revealed poor blood flow of LITA-LAD bypass even after re-anastomosis. We performed coronary angiography and detected a vasospasm in the native coronary arteries, which was not relieved using conventional vasodilators (calcium channel blockers, isosorbide dinitrate, and nicorandil) However, we were able to relieve the coronary vasospasm by administering fasudil (a Rho kinase inhibitor) injection without causing systemic hypotension.

Conclusions

Fasudil may be an important vasodilator, especially in cases of coronary vasospasm after CABG.

Coronary Artery Vasospasm

Coronary artery vasospasm (CVS) is an important mechanism of myocardial ischemia and produces any of the manifestations of coronary artery disease from silent myocardial ischemia, to effort-induced angina and variant angina, to acute coronary syndrome including myocardial infarction or sudden cardiac death. The pathogenesis, characteristic clinical features, diagnosis, and treatment of CVS are summarized. Emphasis is placed on correct diagnosis of CVS using pharmacological spasm provocation test, either during coronary angiography or with echocardiographic monitoring of ventricular wall motion. Current underutilization of pharmacologic provocative test at the time of coronary angiography cannot be justified, as there is no evidence supporting that the incidence of CVS is declining. Physicians' vigilance for objective documentation of CVS is necessary for appropriate management of patients with various clinical presentations of ischemic heart disease.

Coronary artery vasospasm and cardiogenic shock as the initial presentation for eosinophilic granulomatosis with polyangiitis

A 68-year-old woman presented to our hospital with unstable angina and was admitted for further evaluation. While hospitalized, she developed persistent angina with hypotension along with ST-segment elevation in leads V₁-V₂ along with lead aVR elevation on 12-lead electrocardiogram. Coronary angiography revealed diffuse multi-vessel coronary vasospasm most notably in the left anterior descending artery (LAD). Due to incomplete resolution of vasospasm with intracoronary verapamil and nitroglycerin, along with hemodynamic compromise requiring an intra-aortic balloon pump, percutaneous coronary intervention (PCI) of the LAD was performed. Clinical workup revealed hypereosinophlia and elevated IgE; diagnosis of eosinophilic granulomatosis with polyangiitis was confirmed with evidence of radiographic migratory pulmonary infiltrates and airway obstruction on spirometry. The patient had recurrent angina after PCI but her symptoms resolved fully after a course of corticosteroids. We attribute her refractory vasospastic angina to previously undiagnosed small/medium-vessel vasculitis. <Learning objective: We present a case of refractory coronary artery vasospasm in the setting of eosinophilic granulomatosis with polyangiitis (EGPA). Typically, calcium channel blockers and nitrates are used to treat hyperreactive narrowing of the coronary vasculature but we propose this case was refractory to standard treatment due to the underlying pathology of EGPA. Alternative causes of coronary vasospasm when standard therapies fail should be considered.>.

Unraveling of the Effect of Nodose Ganglion Degeneration on the Coronary Artery Vasospasm After Subarachnoid Hemorrhage: An Experimental Study

BACKGROUND

Cardiac arrest is a major life-threatening complication of subarachnoid hemorrhage (SAH). Although medullary cardiocirculatuar center injury and central sympathetic overactivity have been suspected of initiating coronary artery spasm-induced cardiac arrest, we aimed to elucidate the effects of vagal ischemia at the brainstem on coronary vasospasm and sudden death in SAH.

METHODS

Twenty-six rabbits were randomly divided into 3 groups. Control (n = 5); SHAM (n = 8), and SAH group (n = 13). Experimental SAH was applied by injecting homologous blood into the cisterna magna, and the SHAM group was injected with isotonic saline solution also in the cisterna magna., Twenty-one days after the injection, histopathologic changes of the neuron density of nodose ganglia, the vasospasm index values of the coronary arteries, and the electrocardiographic events were analyzed.

RESULTS

Increased vasospasm index of the coronary arteries and degenerated neuron density of nodose ganglion were significantly different between animals with SAH, control, and SHAM groups (P < 0.005). If neurons of the nodose ganglia are lesioned due to ischemic insult during SAH, the heart rhythm regulation by vagus afferent reflexes is disturbed.

CONCLUSIONS

We found that there is causal relationship between nodose ganglion degeneration and coronary vasospasm. Our finding could be the reason that many cardiac events occur in patients with SAH. Vagal pathway paralysis induced by indirect sympathetic overactivity may trigger coronary vasospasm and heart rhythm disturbances. Our findings will aid in the planning of future experimental studies and in determining the clinical relevance of such studies.

Unusual Manifestation of Graves' Disease: Ventricular Fibrillation

BACKGROUND

It is well known that thyrotoxicosis causes rhythm disorders including sinus tachycardia, atrial fibrillation, and atrial flutter. Atrial fibrillation is the most common arrhythmia in thyrotoxicosis, occurring in 5-15% of patients over 60 years of age, whereas ventricular arrhythmia is an unusual manifestation.

CASE REPORT

An 18-year-old Japanese woman was admitted to our emergency department because of loss of consciousness caused by ventricular fibrillation. She had been diagnosed with Graves' disease only 5 days earlier and had no other past medical history. Blood examination showed no obvious abnormality except thyrotoxicosis, and coronary angiography revealed patent coronary arteries. She was diagnosed with thyroid storm due to Graves' disease and is currently healthy during outpatient follow-up.

CONCLUSION

This case highlights that thyrotoxicosis can, albeit extremely rarely, cause ventricular fibrillation even in the absence of hypokalemia or underlying cardiovascular disease.

Scombroid fish poisoning illness and coronary artery vasospasm

We present an interesting case of a young man with coronary artery vasospasm complicating scombroid fish poisoning illness. The initial presentation included tachycardia and significant hypotension. A 12-lead ECG showed sinus tachycardia with marked widespread ST segment depression and ST elevation in aVR. Symptoms subsequently improved with intravenous fluid rehydration, antihistamines, and glyceral trinitrate. The underlying pathogenesis and treatment of this rarely described manifestation of the fish poisoning illness is discussed.

Extracorporeal membrane oxygenation for profound cardiogenic shock due to cocaine toxicity

Cocaine toxicity can result in myocardial infarction from coronary vasospasm. The current treatment algorithm includes intravenous and/or intracoronary vasodilator administration with an expectantly quick resolution of symptoms and signs of ischemia. However, in situations in which myocardial injury persists, the optimal management is uncertain. We present a case in which extracorporeal membrane oxygenation effectively stabilized a patient with ongoing hemodynamic instability who experienced repeated episodes of myocardial injury and ventricular tachyarrhythmias due to cocaine toxicity. <Learning objective: In many urban settings, cocaine-induced angina is not uncommon. The pathogenesis of its manifestation includes coronary artery vasospasm and decreased left ventricular function. Treatment typically involves systemic vasodilators, such as nitrates and calcium channel blockers. However, in patients with substantial hemodynamic instability, these agents might result in a worsening of systemic perfusion. Accordingly, extracorporeal membrane oxygenation should be considered in such cases to promote myocardial recovery.>.

Spontaneous partial regression of coronary artery fistula following optimal medical therapy in a patient who had combined significant coronary artery spasm

Coronary artery fistulas (CAFs) are one of the most rare cardiac anomalies. Some patients with CAF may suffer from ischemic chest pain that originates from combined significant coronary artery spasm (CAS). Spontaneous regression of CAF has been reported in a few cases, almost all of which were infants. We report an adult patient who presented with ischemic chest pain due to multiple coronary arteries to pulmonary artery fistulas and combined significant CAS induced by intracoronary acetylcholine provocation test. Spontaneous regression of one of the fistulas was observed at 2-year angiography follow-up.

A Case of Acute Myocardial Infarction With ST-Segment Elevation in a Lead Augmented Right Vector Caused by a Left Main Coronary Artery Vasospasm

Diagnosing and selecting an appropriate treatment strategy for left main coronary artery (LMCA) obstruction is very important. Although this disease is not frequently encountered, it can cause severe hemodynamic deterioration resulting in a less favorable prognosis without a suitable management approach. Another aspect of LMCA that we must not overlook is coronary artery spasm, which can be an infrequent but important cause of acute coronary syndrome. Although it is rare, LMCA can cause critical complications. In this study, we report the case of a 35-year-old female who was admitted to the hospital with a diagnosis of acute myocardial infarction with ST-segment elevation in the aVR lead caused by a left main coronary spasm that was examined on intravascular ultrasound.