Hiroaki Kohno

Frequency of Provoked Coronary Spasms in Patients Undergoing Coronary Arteriography Using a Spasm Provocation Test Via Intracoronary Administration of Ergonovine

There are no data concerning the incidence of provoked coronary arterial spasms via intracoronary administration of ergonovine (ER). This study sought to establish the incidence of spasms due to intracoronary injection of ER in Japanese patients who underwent coronary angiography. The subjects were 596 consecutive patients (369 men, mean age 64.2 ±10.3 years) who were studied with a selective ER test. ER was administered in total doses of 40 µg into the right coronary artery and 64 µg into the left coronary artery. A positive spasm was defined as a total or subtotal occlusion. Coronary vasospasms were determined in 173 patients (29.0%). Spasms occurred often in patients with ischemic heart disease (43.3%); during effort and rest in patients with angina (46.3%), exertional angina (27.7%), recent myocardial infarction (36.7%), healed myocardial infarction (34.1%), and especially in patients with rest angina (55.5%), but were relatively uncommon in patients with nonischemic heart disease (3.7%). The incidence of provoked coronary spasms in this study was 2.2-2.6 times higher than in previous reports with intravenous ER administration. More spasms were superimposed on significant atherosclerotic lesions than on nonfixed atherosclerotic lesions (42.8% vs 24.0%, p<0.01). No serious or irreversible complications were observed in this study. In conclusion, intracoronary administration of ER was a safe and reliable test. Compared with Caucasian patients, in Japanese patients, coronary arterial spasms occurred 2-3 times more frequently with various cardiac disorders.

Clinical impact of selective spasm provocation tests: comparisons between acetylcholine and ergonovine in 1508 examinations.

BackgroundThere are few reports regarding the concordance of coronary arterial response between acetylcholine (ACh) and ergonovine (ER) spasm provocation tests. ObjectivesWe attempted to perform selective spasm provocation tests to examine the incidence of provoked spasm in patients who had undergone first coronary angiography as much as possible and we compared the coronary arterial response and clinical usefulness between selective intracoronary injection of ACh and intracoronary administration of ER. MethodsWe performed 1508 selective spasm provocation tests, consisting of 873 ACh tests and 635 ER tests, from 1991 to 2002. We examined the frequency of provoked spasms of each agent retrospectively. ACh was injected in incremental doses of 20, 50 and 80u2009μg into the right coronary artery and 20, 50 and 100 μg into the left coronary artery. ER was administered as 10u2009μg/min over 4u2009min for a maximal dose of 40u2009μg in the right coronary artery and as 16u2009μg/min over 4u2009min for a total dose of 64u2009μg in the left coronary artery. Coronary spasm was defined as transient >99% luminal narrowing. ResultsIntracoronary ACh provoked spasms in 36.0% of patients and intracoronary ER induced spasms in 29.8% of patients. In patients with ischemic heart disease, the incidence of provoked spasms was not different between ACh tests (50.9%) and ER tests (43.8%). In contrast, the frequency of provoked spasms with ACh tests was significantly higher than that with ER tests (11.0% compared with 6.4%, P<0.05) in patients without ischemic heart disease. Moreover, ACh provoked more spasms in patients without fixed stenosis than ER (36.2% compared with 25.5%, P<0.01) and multiple spasms were frequently observed when performing ACh tests (40.0% compared with 27.0%, P<0.01). Major complications were observed in 1.4% of patients with ACh tests and in 0.2% of patients with ER tests. The need for intracoronary administration of isosorbide dinitrate to relieve coronary spasms during ER testing before performing another coronary artery test was more frequently observed in ACh tests (5.04% compared with 1.49%, P<0.01). However, no serious irreversible complications, such as death or acute myocardial infarction, were observed in this study. There was a significant difference in sex, history of smoking and hyperlipidemia between patients with and without spasms for both tests, whereas no difference in age or hypertension was observed in either test. ConclusionThus, both selective ACh and ER tests were useful as spasm provocation tests.

Clinical and angiographical characteristics of acetylcholine- induced spasm: relationship to dose of intracoronary injection of acetylcholine.

ObjectivesThe purpose of this study was to clarify clinical and angiographical characteristics of acetylcholine (ACh)-induced spasm in the right and left coronary artery. Methods and resultsWe performed 557 consecutive procedures of spasm provocation tests of ACh from January 1991 to December 2000 in patients without significant stenosis. ACh was injected in incremental doses of 20, 50 and 80u2009μg into the right coronary artery and in incremental doses of 20, 50 and 100u2009μg into the left coronary artery if spasm had not been provoked. Coronary spasm was defined as positive with more than 99% transient luminal narrowing. Proximal spasm was defined as that of segments 1, 2, 5, 6, 7 and 11 and distal spasm as that of segments 3, 4, 8, 9, 12, 13 and 14. Low-ACh-dose-induced spasms showed the clinical findings and angiographical characteristics of higher incidence of variant angina, proximal spasms, focal spasms, more ST elevation and ischemic heart disease. In contrast, angiographical characteristics of high-Ach-dose-induced spasms were distal spasms and diffuse spasms and there was less variant angina and less ST elevation. ConclusionsLower ACh doses induced spasms more proximally and focally in the coronary artery, while higher doses of ACh provoked spasms more distally and diffusely.

A long-acting calcium antagonist over one year did not improve BMIPP myocardial scintigraphic imagings in patients with pure coronary spastic angina.

Background: Calcium antagonists (Ca) have been effective in reducing angina attacks in patients with variant angina. However, there are no reports regarding the effectiveness of Ca on myocardial fatty acid metabolic images in patients with pure coronary spastic angina (CSA).Objectives: This study sought to examine the correlation between myocardial fatty acid metabolic images and the medical treatment of Ca in patients with pure CSA.Methods and Results: This study included 35 consecutive patients (28 men, mean age of 66±10 years) with angiographically confirmed coronary spasm and no fixed stenosis. Long-acting Ca was administered to all 35 patients. Isosorbide dinitrate /nicorandil/another Ca/beta-bloker were administered when chest pain was not controlled. Using an iodinated fatty acid analogue, 15-(p-[iodine-123]iodophenyl)-3-(R,S)methylpentadecanoic acid (BMIPP), myocardial scintigraphies with intravenous adenosine triphosphate infusion were performed before cardiac catheterization and 12 mo after medical therapy. According to the medical control states, these 35 patients were classified into 3 groups; response (disappearance of angina attacks, 12 pts, 60±11 years), partial response (angina attacks <4/mo, 12 pts, 67±10 years), and no response to therapy (angina attacks ≥4/mo, 11 pts, 71±6 years). Reduced BMIPP uptake was observed in 24 (69%) of 35 patients before the treatment. Reduced BMIPP uptake was also found in 18 patients (51%) after 12 mo. Normal BMIPP uptake after 12 mo therapy was observed in about half (response: 42%, partial response: 58%, no response: 45%) of patients among the 3 groups. There was no difference regarding the value of washout rate (WOR) (response; 10±7 (before), 14 ±8% (12 mo)), partial response; 11±7, 10±5%, no response; 13±9, 14±8%) among the 3 groups. The defect scores of BMIPP in the three groups were not different during at least one year medical therapy. No difference regarding the distribution of other medical therapies (angiotensin converting enzyme inhibitors/angiotensin receptor blockers/beta-blockers/statins) was found. The administration of Ca and isosorbide dinitrate/nicorandil and 2 Ca was significantly higher in the poor than in the good control patients.Conclusions: Long-acting Ca over one year did not improve myocardial fatty acid metabolic images in patients with pure CSA. This may be related to silent ischemia.