Vasospastic angina: a review on diagnostic approach and management

Vasospastic angina (VSA) refers to chest pain experienced as a consequence of myocardial ischaemia caused by epicardial coronary spasm, a sudden narrowing of the vessels responsible for an inadequate supply of blood and oxygen. Coronary artery spasm is a heterogeneous phenomenon that can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction (MI). VSA was originally described as Prinzmetal angina or variant angina, classically presenting at rest, unlike most cases of angina (though in some patients, vasospasm may be triggered by exertion, emotional, mental or physical stress), and associated with transient electrocardiographic changes (transient ST-segment elevation, depression and/or T-wave changes). Ischaemia with non-obstructive coronary arteries (INOCA) is not a benign condition, as patients are at elevated risk of cardiovascular events including acute coronary syndrome, hospitalization due to heart failure, stroke and repeat cardiovascular procedures. INOCA patients also experience impaired quality of life and associated increased healthcare costs. VSA, an endotype of INOCA, is associated with major adverse events, including sudden cardiac death, acute MI and syncope, necessitating the study of the most effective treatment options currently available. The present literature review aims to summarize current data relating to the diagnosis and management of VSA and provide details on the sequence that treatment should follow.

Acute coronary syndrome due to multi-vessel coronary artery spasm in an Afghan refugee adolescent mimicking recurrent myocarditis

Vasospastic angina is extremely uncommon for adolescents to experience chest discomfort, which is defined by transitory ST segment elevation or depression and angina symptoms that occur while at rest. It may result in potentially fatal conditions like myocardial infarction, ventricular fibrillation, or even sudden cardiac arrest. To aim of this article is to report a very rare case of a 17-year-old male Afghan refugee who was diagnosed with vasospastic angina after presenting with chest pain, and after receiving calcium channel blocker and nitrates for medical therapy, there were no angina attacks. Our case underlines the value of a thorough evaluation of adolescent's chest pain, the need to diagnose based on the symptoms, and the necessity of performing coronary angiography to rule out coronary causes when there is a high suspicion to a cardiac cause.

Prinzmetal angina in a child with actin gene ACTC1 mutation

Prinzmetal angina is a rare cause of intermittent chest pain in paediatrics. Here, we report the case of a 2-year-old female who presented with episodic chest pain, malaise, diaphoresis, fatigue, and poor perfusion on exam. During her hospitalisation, these episodes were associated with significant low cardiac output as evidenced by lactic acidosis and low mixed venous oxygen saturations. Her workup revealed an actin alpha cardiac muscle 1 (ACTC1) gene mutation and associated left ventricular non-compaction with decreased systolic function. She was started on oral heart failure medications as well as a calcium channel blocker but continued to have episodes which were found to promptly resolve with nitroglycerine. She was ultimately listed for cardiac transplant given her perceived risk of sudden death.

Variant Angina with Spontaneously Documented Ischemia- and Tachycardia-induced "Lambda" Waves

In a patient with variant angina of the proximal left anterior descending coronary artery, myocardial ischemia changed the QRS-ST-T configurations without J-waves into those resembling "lambda" waves at maximal ST-segment elevation, and couplets or triplets of supraventricular extrasystole (SVE) changed the ischemia-induced "lambda" waves into QRS-ST-T configurations resembling a "tombstone" morphology or "monophasic QRS-ST complex." At the resolution phase of coronary spasm, the QRS-ST-T configurations returned to those without J-waves and were changed by SVE into "lambda" waves. Interestingly, neither ischemia- nor SVE-induced "lambda" waves or SVE-induced "tombstone" morphology or "monophasic QRS-ST complex" were complicated by ventricular tachyarrhythmia.

Prinzmetal Angina Mimicking Severe Three-Vessel Coronary Artery Disease

Coronary artery vasospasm, or Prinzmetal angina, remains a challenging diagnosis. Prinzmetal angina usually affects only one coronary vessel; however, in this case, it occurred simultaneously in three coronary arteries, and was totally relieved after nitrate administration.

Variant angina induced by carbon monoxide poisoning: A CARE compliant case report

RATIONALE

Carbon monoxide (CO) poisoning can cause severe damage to the nervous system, and can also cause serious damage to organs, such as the heart, kidneys, and lungs. CO damage to myocardial cells has been previously reported. This can lead to serious complications, such as myocardial infarction.

PATIENT CONCERNS

A 47-year-old female patient complained of sudden chest pain for 30 minutes. Before admission, the patient had non-radiating burning chest pain after inhalation of soot.

DIAGNOSIS

An electrocardiogram showed that myocardial ischemia was progressively aggravated, manifested by progressive ST-segment elevation, and accompanied by T wave inversion and other changes. No obvious coronary stenosis was observed in a coronary angiographic examination. Therefore, the patient was considered to have developed variant angina resulting from CO poisoning-induced coronary artery spasm.

INTERVENTIONS

The patient was treated with drugs for improving blood circulation and preventing thrombosis, and underwent hyperbaric oxygen therapy.

OUTCOMES

Clinical symptoms relieved after the treatment.

LESSONS

Findings from this case suggest that CO can cause coronary artery spasm and it is one of the predisposing factors of variant angina. For these patients, hyperbaric oxygen therapy can improve blood circulation and prevent formation of thrombus and encephalopathy.

Fluctuations in the amplitude of ST-segment elevation in vasospastic angina: Two case reports

RATIONALE

ST-segment elevation localizes an ischemic lesion to the coronary artery supplying the area of the myocardium reflected by the electrocardiographic leads. Dynamic ST-segment elevation can be due to severe transmural ischemia secondary to a thrombus, vasospasm, or a tightly fixed coronary artery lesion or a combination of these situations.

PATIENT CONCERNS

In this study, we report on two patients with angina who had fluctuations in ST-segment amplitude on serial electrocardiograms. The amplitude of ST-segment elevation varied between 1-20 mm.

DIAGNOSES

Vasospastic angina (VSA) was diagnosed based on electrocardiography and coronary angiography.

INTERVENTIONS

Calcium antagonists were prescribed for both patients.

OUTCOMES

No recurrent VSA was noted during outpatient follow-up.

LESSONS

VSA can be associated with fluctuations in the amplitude of ST-segment elevation, indicating dynamic coronary vasospasm in different locations and extensions in patients with VSA.

Provocation of Coronary Vasospastic Angina Using an Isoproterenol Head-up Tilt Test

The goals of this study were to determine the value of the isoproterenol (ISO) head-up tilt (HUT) test in detecting coronary vasospastic angina and to investigate the possible mechanism responsible for coronary artery spasm. The ISO + HUT test was performed in 16 patients with coronary artery spasm documented by the intracoronary ergonovine provocation test. Patients’ blood pressure and heart rate were measured at baseline, during the ISO + HUT (phase I), and during HUT after discontinuation of ISO (phase II). Patients were categorized as test-positive if they developed angina with ST-segment elevation during testing. Eight patients (50%) were test-positive (5 in phase I and 3 in phase II). Between the test-positive and test-negative groups, no significant differences were noted in the changes in blood pressure throughout the test. However, there were significant differences in the changes in heart rate from supine to 2 minutes after HUT under ISO infusion (-17 ±22 vs 11 ±25 beats/minute; p=0.035). In those patients with a positive result in the phase I stage, the heart rate decreased initially after tilt-up, and then significantly increased later (from 85 ±16 to 110 ±27 beats/minute; p=0.043), when coronary vasospasm occurred. In those patients with a positive result in the phase II stage, coronary vasospasm occurred immediately after HUT, when there was an insignificant transient increase in heart rate from the supine to the HUT position (from 85 ±12 to 92 ±11 beats/minute; p=0.109). The ISO + HUT test can provoke coronary vasospasm with ST-segment elevation in 50% of the patients with coronary artery spasm, when combined with an extensional protocol of HUT after discontinuation of ISO. This study suggests that the induction of coronary artery spasm during HUT testing is associated with a rapid elevation of sympathetic activity during augmented parasympathetic activity.

Clinical implications of low-dose aspirin on vasospastic angina patients without significant coronary artery stenosis; a propensity score-matched analysis

BACKGROUND

High-dose aspirin has been reported to exacerbate coronary artery spasm in patients with vasospastic angina. We investigated clinical implications of low-dose aspirin on vasospastic angina patients without significant coronary artery stenosis.

METHODS

We included patients without significant coronary artery stenosis on coronary angiography (CAG) and with positive results on intracoronary ergonovine provocation test between January 2003 and December 2014. A total of 777 patients were divided into two groups according to prescription of low-dose aspirin at discharge: aspirin group (n=321) and non-aspirin group (n=456). The major adverse cardiovascular events (MACE), defined as composite outcomes of cardiac death, acute myocardial infarction, revascularization, or rehospitalization requiring CAG or medication change due to recurrent angina were compared.

RESULTS

The aspirin group had significantly higher incidence of MACE (22.8% versus 12.1%; p=0.04) and had higher tendency for rehospitalization (20.6% versus 11.2%; p=0.08). All-cause mortality and cardiac death were similar between the two groups. After propensity score matching, the aspirin group had greater risk of MACE (hazard ratio [HR] 1.54; 95% confidence interval [CI], 1.04-2.28; p=0.037) and rehospitalization requiring CAG (HR, 1.33; 95% CI, 1.13-4.20; p=0.03), and a higher tendency for rehospitalization (HR, 1.40; 95% CI, 0.94-2.09; p=0.12).

CONCLUSION

In vasospastic angina without significant coronary artery stenosis, patients taking low-dose aspirin are at higher risk of MACE, driven primarily by tendency toward rehospitalization. Low-dose aspirin might be used with caution in vasospastic angina patients without significant coronary artery stenosis.

Anginalike pain and normal coronary arteries

Atherosclerotic CAD is the most common cause of cardiac chest pain in Western countries. Other cardiac syndromes may also cause anginalike pain and may be difficult to differentiate from atherosclerotic CAD. It is essential to make this distinction, because management and prognosis of these conditions are entirely different. A detailed history and, in some cases, special diagnostic methods can help make the diagnosis. When evaluating patients with anginalike chest pain and normal coronary arteries, physicians need to consider this group of diseases and tailor workup and diagnosis on an individual basis.

Angina with "normal coronary arteries". A misnomer

Angina with "normal coronary arteries" might best be thought of as "angina with coronary dysfunction". It seems likely that this syndrome is due to inadequate regional myocardial perfusion with manifestations similar to those seen when ischemia results from occlusive coronary artery disease. The prognosis of the disorder is favorable, but occasional catastrophic events occur. It appears likely that maldistribution of perfusion results from dynamic changes affecting proximal, and perhaps distal coronary vessels, potentially mediated by vasoactive substances released from platelets precipitating or exacerbating coronary arterial spasm. Clarification of the pathogenesis of the syndrome should permit implementation of more effective therapy and prevention of the rare malignant sequelae of this disorder.

[Many possible causes of variant angina]

BACKGROUND

Variant angina, or vasospastic angina, is a form of angina caused by vasospasm of the coronary arteries, probably caused by endothelial dysfunction. This form of angina is provoked by non-classical risk factors such as stress, alcohol use, use of sympathomimetics and low environmental temperatures, but also by smoking. Treatment is based on elimination of risk factors and vasodilator therapy with nitrates and long-acting calcium antagonists.

CASE DESCRIPTION

We present a 68-year-old woman with recurring thoracalgia at rest and during exercise, suggestive of severe variant angina in more than one coronary artery. Despite elimination of risk factors and administration of vasodilatory therapy the treatment was initially insufficient. It eventually emerged that the probable cause was frequent use of a vasoconstrictive nasal spray, although this was not described in literature, and not originally mentioned by the patient.

CONCLUSION

A thorough case history is of vital importance in a patient presenting with a history suggestive of variant angina. Even undescribed and apparently less important risk factors can be responsible for persistence of symptoms, and can lead to an applied treatment not producing the desired result.

Rare giant T-wave inversions associated with myocardial stunning: report of 2 cases

Prominent T-wave inversions are well recognized electrocardiographic signs that can occur in acute myocardial infarction (AMI). However, the giant negative T waves may be associated with myocardial stunning without AMI.This case report describes 2 patients without AMI who developed rare giant T-wave inversions measuring up to 35 mm in depth and QT prolongation after admission to hospital. While 1 patient presented with acute pulmonary edema, the other patient presented with severe chest pain at rest and transient ST elevation.The giant T-wave inversion with QT prolongation may be caused by myocardial stunning due to the triple vessel diseases and elevated wall stress, high-end diastolic pressure and decreased coronary arterial flow during pulmonary edema in the first patient. The giant T-wave inversion with QT prolongation in the second patient may be caused by myocardial stunning due to the left anterior descending artery spasm (transient ST elevation) leading to transient total occlusion of left anterior descending artery. Percutaneous coronary intervention was successfully undergone for both patients. The patients remained well.The electrophysiologic mechanism responsible for giant T-wave inversion with QT prolongation is presently unknown. The two cases demonstrate that the rare giant negative T waves may be associated with myocardial stunning without AMI.

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 vasomotor response to intracoronary acetylcholine injection, clinical features, and long-term prognosis in 873 consecutive patients with coronary spasm: analysis of a single-center study over 20 years

BACKGROUND

The aim of this study was to elucidate the correlation between angiographic coronary vasomotor responses to intracoronary acetylcholine (ACh) injection, clinical features, and long-term prognosis in patients with vasospastic angina (VSA).

METHODS AND RESULTS

This is a retrospective, observational, single-center study of 1877 consecutive patients who underwent ACh-provocation test between January 1991 and December 2010. ACh-provoked coronary spasm was observed in 873 of 1637 patients included in the present analysis. ACh-positive patients were more likely to be older male smokers with dyslipidemia, to have a family history of ischemic heart disease, and to have a comorbidity of coronary epicardial stenosis than were ACh-negative patients. ACh-positive patients were divided into 2 groups: those with focal (total or subtotal obstruction, n=511) and those with diffuse (severe diffuse vasoconstriction, n=362) spasm patterns. Multivariable logistic regression analysis identified female sex and low comorbidity of coronary epicardial stenosis to correlate with the ACh-provoked diffuse spasm pattern in patients with VSA. Kaplan-Meier survival curve indicated better 5-year survival rates free from major adverse cardiovascular events in patients with diffuse spasm pattern compared with those with focal spasm pattern (P=0.019). Multivariable Cox hazard regression analysis identified diffuse spasm pattern as a negative predictor of major adverse cardiovascular events in patients with VSA.

CONCLUSIONS

ACh-induced diffuse coronary spasm was frequently observed in female VSA patients free of severe coronary epicardial stenosis and was associated with better prognosis than focal spasm. These results suggest the need to identify the ACh-provoked coronary spasm subtypes in patients with VSA.

Cardiopulmonary arrest caused by coronary spasm after coronary vasodilator withdrawal during the peri-operative period of gastrectomy

Calcium antagonists, nicorandil and long-acting nitrates are highly effective for preventing coronary spasm. The withdrawal of coronary vasodilators, especially calcium antagonists, is risky in cases of vasospastic angina. We herein present a case of cardiopulmonary arrest that occurred due to coronary spasm triggered by the discontinuation of coronary vasodilators during the peri-operative period of gastrectomy. Vasospastic angina patients who are not able to take oral coronary vasodilators in the peri-operative period should be maintained on a parenteral vasodilator until they are able to take them orally. Physicians should also be aware of the possible development of nitrate tolerance in patients on prolonged nitrate therapy.

[Hyperventilation echocardiography in vasospastic angina pectoris diagnosing]

Hyperventilation echocardiography is an established diagnostic test in patients with suspected variant angina pectoris. It has got sufficient sensitivity (60-80%) and specificity (85-100%). Positive hyperventilation test is rarely found, which relates to low prevalence of variant angina. The diagnostic yield of the test depends on the population selected for testing: positive result can be expected in patients with a history of typical burning chest pain, ST segment elevation/depression and/or inversions of U wave during the chest pain episode, arrhythmias related to the chest pain, coronary artery stenosis less than 50% of artery diameter, multi-vessel disease, high activity of illness at the time of hyperventilation test. We present a case of 37 years old man with typical angina pectoris at rest and non-Q myocardial infarction, in whom the coronary angiography was negative. Variant angina pectoris was diagnosed by hyperventilation echocardiography. The ECG tracings showing typical ischemic patterns during the hyperventilation test are included.

Prinzmetal angina in the differential diagnosis of syncope

Prinzmetal (variant) angina may be associated with cardiac arrhythmias that can deteriorate to fatal ventricular arrhythmias. We present 2 patients with syncope where vasospastic angina and severe ventricular arrhythmias were found to be responsible for the syncopal episodes.

Differential local spasticity in myocardial bridges

To illustrate the effect of myocardial bridges on coronary vascular tone, we describe the cases of 2 patients with different clinical presentations in the context of reproducible increased spasticity at the site of myocardial bridging. One had an episode of takotsubo cardiomyopathy, and one developed typical Prinzmetal angina while receiving desmopressin treatment for pituitary insufficiency. In both patients, acetylcholine challenge clearly revealed both the presence and the severity of myocardial bridging while producing several recognizable degrees of abnormal spastic tendency.Both baseline functional states and responses to different medications correlate with spastic tendency and enable the characterization of individual cases. Understanding the spectrum of spastic conditions might help to clarify the causes of atypical ischemic events, especially in patients with myocardial bridging.

Complications of variant angina: a case report

The case of a patient with Prinzmetal's angina causing syncope due to atrioventricular block, and later causing death, is presented. Electrocardiogram during the episodes demonstrate multiple coronary artery involvement. Detection and differential diagnosis of ST-segment elevation during paced rhythm is discussed.

[Variant angina: what to think in 2011?]

Spastic angina is considered rare but its prevalence is probably underestimated especially in case of atherosclerotic coronary lesions. Its diagnosis remains important due to its poor prognosis and therapeutic characteristics. We report three clinical cases illustrating two different clinical presentations and the problem of diagnosis of spastic angina. We performed a review of the literature essentially concerning commonly used diagnosis means and especially provocative testing for coronary spasm. This test needs to be adapted to the evolution of techniques and uses of coronary angiography in 2011, particularly the wide spread use of radial approach. Therefore new recommendations are needed, specifying the terms of provocative testing and establishing clear diagnosis criteria including clinical, electrocardiographic and angiographic data. Such guidelines would probably help to better diagnose and treat these patients in our practice.

Severe coronary artery spasm induced by epidural injection of bupivacaine hydrochloride: a case report

This report describes a case of variant angina induced by epidural infusion of bupivacaine hydrochloride for the treatment of intractable low back pain in a 66-year-old male patient with lumbar discopathy. Severe reversible coronary artery spasm of right coronary artery was demonstrated by coronary angiography. Withdrawal of epidural anesthesia and treatment with nitrates and calcium channel antagonists resulted in cessation of variant angina.

Variant angina associated with coronary artery endothelial dysfunction and myocardial bridge: a case report and review of the literature

The association of variant angina (VA) and myocardial bridges is a rare finding. We describe a case of VA with recurrent coronary spasm triggered by different stimuli at the site of a myocardial bridge. The interplay of endothelial dysfunction, coronary vasoconstriction and myocardial bridging was detected by intracoronary acetylcholine test and IVUS. We speculate that mechanical stimulation at the bridge site caused endothelial dysfunction and enhanced local susceptibility to vasoconstrictor stimuli. Variant angina should always be suspected in cases of ST-elevation acute coronary syndrome without any significant angiographic coronary stenosis.

An unusual case of pulseless electrical activity arrest associated with Prinzmetal's angina

Cardiac arrest due to ventricular tachyrhythmia in the setting of Prinzmetal's angina (PA) has been well reported in the literature. However, to our knowledge, there have been no reports of a pulseless electrical activity (PEA) arrest in patients with PA. We report a case of PEA arrest in a patient with PA after surgical drainage of an abscess in the first web-space of the left hand. We propose that the Bezold-Jarisch reflex may be the underlying mechanism responsible for this arrest. The case also highlights the danger of ceasing treatment with nitrates and calcium channel blockers in patients with PA.

Prinzmetal's variant angina is effectively treated with enhanced external counterpulsation

A 57-year-old woman suffering from severe Prinzmetal's angina was treated with a 7-week course of enhanced external counterpulsation (EECP). After completing EECP the angina intensity was reduced from CCS class IV to class I, quality of life was increased and medication was significantly reduced. The number of hospitalisations due to chest pain was reduced from 81 in the two years before EECP to 2 in the two years after EECP. To our knowledge, this is the first report demonstrating the effect of EECP on Printzmetal's angina.

Improved myocardial perfusion preceding clinical response on bosentan treatment for coronary vasospasm

Many patients suffer from persistent angina due to coronary vasospasm despite optimal medical treatment. We treated a 46-year-old patient with severe and treatment-resistant coronary vasospasm with the endothelin-receptor antagonist bosentan. Using oxygen-15-labelled water in conjunction with oxygen 15-labelled carbon monoxide positron emission tomography (PET), we measured an impaired coronary flow reserve (CFR) in 6 out of 13 segments directly before the start of bosentan therapy. A repeated PET measurement after 16 weeks of bosentan revealed a completely normalized CFR in this patient. Furthermore, the patient reported less frequent and less severe chest pain. Our data suggest a potential role of endothelin-receptor antagonists for patients with severe coronary vasospasms.

Vasospastic angina: control of disease activity and efficacy of drug treatment using the prolonged hyperventilation test

Sixteen consecutive patients with vasospastic angina underwent a control provocation test in the coronary care unit or the cardiac catheterization laboratory in order to evaluate the disease activity and the efficacy of long-term calcium antagonist treatment. In patients without angina at rest, the prolonged hyperventilation test was negative in 10/10 patients on calcium antagonist treatment (group A + B) and in 4/5 patients without medication (group C). The test was positive in 1/1 patient with angina at rest without medication (group D). However, the test provoked vasospastic angina in 1/5 patients who were asymptomatic without medication. In both the latter patients the prolonged hyperventilation test became negative after the restart of calcium antagonist treatment. During a mean follow-up period of 18 months (range 16-19) after the control hyperventilation test, no relapse of angina at rest, arrhythmias, syncopes, deaths or myocardial infarctions were registered. Thus, a negative test is compatible with low disease activity and/or efficacy of calcium antagonist treatment. Further, the test may reveal a subclinical tendency to coronary artery spasm.

[Case of undiagnosed vasospastic angina first noted during anesthesia]

A 75-year-old man patient was scheduled for total gastrectomy, splenectomy, and cholecyctectomy who had been hypertensive. The patient had no symptoms related to cardiac disease before surgery. Preoperative ECG showed only complete right bundle branch block. After arriving in the operating room, epidural anesthesia was performed at the T8-9 inter space and general anesthesia was induced with propofol without difficulty. Before operation, suddenly PVCs appeared, followed by VT and VF. Immediately the patient was treated with defibrillation, nitroglycerin and nicorandil. The operation was canceled. Vasospastic angina was diagnosed by acetylcholine infusion test postoperatively. Most of patients with vasospastic angina show elevation of ST segment on ECG at first, but our case showed VT and VF without ST elevation on ECG.

Prinzmetal's variant angina

Although the prevalence of variant angina pectoris is unknown, it appears to be substantially less common than typical, exertional angina and unstable angina at rest. The patient with variant angina typically complains of a pressure-like, squeezing retrosternal chest discomfort of several minutes duration. The diagnosis is secured by the occurrence of transient ST-segment elevation in association with chest pain, both of which resolve spontaneously or with nitroglycerin. After the diagnosis is made, the patient usually becomes symptom-free on calcium-channel blockers with or without long-acting nitrates. Although the long-term survival of these patients is excellent, an occasional individual with variant angina sustains a complication, most often myocardial infarction, a life-threatening arrhythmia, or sudden cardiac death.

Prinzmetal angina

Prinzmetal angina is a syndrome of cyclical chest pain at rest caused by vasospasm and associated with ST-segment elevation.

[Bouts of chest pain]

We report on a 46-year-old man with vasospastic angina. The differential diagnosis, the eventful course of the patient and in particular the clinical image with diagnostic approach, therapy and prognosis of vasospastic angina are discussed.

[Extraction, combination and distribution regularity of syndrome elements in patients with variant angina pectoris]

OBJECTIVE

To explore the pathogenesis characteristics of variant angina pectoris (VAP) by extracting its syndrome elements and analyzing the combination and distribution regularity of the syndrome elements.

METHODS

One hundred and seventy-five case files of VAP patients were collected. The extraction of syndrome elements and symptom contribution to syndrome was completed by the partition method of complex system based on entropy theory. Diagnostic threshold was established by receiver operator characteristic curve. According to the results diagnosed by diagnostic criteria for syndrome element with quantitation, the combination and distribution regularity of the syndrome elements in patients with VAP was analyzed.

RESULTS

The basic syndrome elements in the patients with VAP were qi deficiency, qi stagnation, blood stasis, phlegm turbidity, phlegm-heat, stagnation-heat, yin deficiency and yang deficiency syndromes. It showed that the combination types of syndrome elements could be made up of one syndrome, two, three, four or more than four syndromes. Qi deficiency, yin deficiency, qi stagnation, blood stasis and phlegm turbidity syndromes had the higher frequency than other syndrome elements in the patients with VAP.

CONCLUSION

The partition method of complex system based on entropy theory can be used in extracting the syndrome elements of the patients with VAP. It is found that VAP has complicated pathogenesis according to the combination and distribution regularity of syndrome elements. Qi deficiency, qi stagnation, blood stasis, phlegm turbidity and yin deficiency syndromes are the main syndrome elements.

[Prinzmetal's angina: clinical manifestation in a 79-year-old man with atherosclerotic coronary artery disease]

A case of a 79-year-old man with risk factors of ischaemic heart disease is presented. He was admitted to the Cardiology Ward because of recurrent angina pectoris with ST-segment elevation in the anterior electrocardiographic leads. Coronary arteriography revealed 90% stenosis of the marginal branch of the left coronary artery, which was supplied by coronary angioplasty. During hospitalisation recurrent episodes of angina pectoris were noted, only in night hours, with ST-segment elevations in anterior electrocardiographic leads. Pharmacotherapy with calcium blockers and nitrates eliminated the episodes of chest pain in a ten-month follow-up.

[61 years old woman with atypical angina and high global risk]

Bei einer 61-jährigen Frau mit blander Vorgeschichte entwickelt sich eine Dyspnoesymptomatik, die von einer labilen Hypertonie begleitet ist. Die kardiologische Abklärung ergibt bei Hyperventilationsneigung ein pathologisches Belastungs-EKG, jedoch eine überdurchschnittlich gute ergometrische Leistungsfähigkeit. Die Befundkonstellation spricht gegen eine koronare Problematik, sodass auf eine zusätzliche funktionelle oder invasive Abklärung verzichtet wird. Angesichts des auf 19% erhöhten, intermediären Globalrisikos wird zum Ausschluss einer koronaren Herzkrankheit eine CT-Koronarangiographie durchgeführt. Diese ergibt überraschend eine ca. 50%ige weiche Plaque im proximalen RIVA. Die hsCRP ist erhöht, was eine potentielle Plaque-Vulnerabilität anzeigen könnte. Trotz einem Calcium-Score von 0 wird die Patientin als hohes Risiko eingestuft und mit Aspirin und einem hoch dosierten Statin behandelt. Für dieses Vorgehen besteht bisher keine Evidenz. Auf Grund des Calcium-Score allein wäre nach geltender Empfehlung das intermediäre Risiko auf ein niedriges zurückgestuft worden [4].