Ergonovine maleate test detects anginal patients with poorly reproducible exercise tests

The aim of the study is to evaluate the reproducibility of exercise testing and to determine whether there is any correlation between the reproducibility of exercise test and response to the ergonovine maleate test. Thirty-eight patients with mixed angina and documented coronary artery disease underwent an ergonovine maleate test and four exercise tests on consecutive days in the same basal conditions. The ergonovine test was positive in 20 patients (Group I) and negative in 18 patients (Group II). There were no significant differences in the clinical and angiographic data of the two groups. All 152 exercise tests were positive. The variability of the response of the repeated tests was assessed by means of an analysis of the following parameters: heart rate, blood pressure, rate-pressure product, watts, and minutes were recorded at the onset of ischemia (ST decreases greater than or equal to 0.1 mV). Range (maximal-minimal obtained value), ratio between range and maximal obtained value, and coefficient of variation (standard deviation/mean of the four parameters) were calculated for each patient. The analysis of these values demonstrated that while the test was reproducible in some patients, a high individual variability was present in others. Moreover, the individual variability results were higher in Group I than in Group II, with a statistically significant difference for all considered parameters. In conclusion, it is possible to have a poorly reproducible exercise test in patients with mixed angina. The correlation between a positive ergonovine test and a poorly reproducible exercise test suggests that abnormal coronary vasomotion may sometimes be present during exercise and may affect the reproducibility of the test.     

Coronary arterial spasm in angina at rest associated with transient ST-segment changes

In order to clarify the role of coronary arterial spasm in the pathogenesis of angina at rest, coronary arteriography was performed during spontaneous chest pain or following intravenous administration of ergonovine maleate in 40 patients with angina at rest. Coronary vasospasm was demonstrated in 23 patients with ST-segment elevation during chest pain (group I), in 7 with ST-segment depression (group II), and in 4 with both ST-segment depression and elevation (group III). Complete spastic occlusion of the proximal or of the midportion of the left anterior descending artery was always associated with ST-segment elevation in anterior leads. In contrast, transient ST-segment depression in anterior leads was associated with diffuse narrowing of the left anterior descending artery with slow progression of the contrast medium, or complete occlusion of a small branch or of the distal segment of the left anterior descending artery. ST-Segment elevation in inferior leads was associated with complete spastic occlusion or with significant spastic narrowing of the right coronary artery or of the circumflex artery. We conclude that coronary spasm can be demonstrated in a selected cohort of patients with angina at rest associated with transient ST-segment changes. In some cases the site and the severity of the spasm may produce varying degrees of ischemia, thus determining the direction of the ST-segment shift.     

Exercise Stress Testing in Angina Patients with Positive Response to Hyperventilation Testing: Influence of the Coronary Artery Tone

ABSTRACT We studied the exercise stress test and the coronary artery tone in two groups of angina patients with comparable coronary atherosclerosis. Group I (20 males and 5 females, mean age 53.5 years) with a positive, and group 11 (22 males and 3 females, mean age 52.5 years) with a negative response to the hyperventilation test (HVT). A positive exercise stress test (ST depression ≥1 mm) was found in 24 patients in group 1 vs. 15 in group II (p<0.01), despite a lower maximal rate pressure product (198±11.2 vs. 236±10.1, p<0.05) and maximal work load (110 W±7.1 vs. 136±7.4 W, p<0.02) in group I. A high coronary artery tone (dilatation (DIL %) of the coronary arteries after nitroglycerin ≥ 10%) was found in 18 patients in group I and in 4 in group II (p<0.01). DIL % was 22.6±3.8 vs. 5.8±1.4 in groups I and II, respectively (p<0.005). DIL% was significantly related to persistence of ST depression after exercise (r=0.36, p<0.05), and 21 of 22 patients with high tone had a positive exercise stress test vs. 18 of 28 with low tone (p<0.05). These findings suggest that the coronary artery tone influences the response to exercise in some patients with angina. Since the patients in group I were identified by HVT, our results underline the clinical relevance of this test.     

Vasospastic Angina: Control of Disease Activity and Efficacy of Drug Treatment Using the Prolonged Hyperventilation Test

ABSTRACT 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.     

Ergonovine maleate test in various anginal syndromes

The ergonovine maleate (EM) test has been performed in fourgroups of 10 patients each: (A) variant angina; (B) angina atrest with ST segment depression during pain; (C) effort angina;(D) atypical chest i pain. EM was injected i.v. (highest dose 0-4 mg) first in the CoronaryCare Unit and thereafter during coronary angiography. EM causedcoronary spasm with angina and ST segment elevation in everypatient of group A and in one patient of group B. In five and four patients of groups B and C, respectively, EMinduced angina and ST segment depression without any localizedcoronary spasm, the coronary angiography showing only a diffusenarrowing of the coronary vessels; these patients had the lowesteffort tolerance and the most severe coronary lesions. Spontaneous or induced coronary spasm in patients with anginaat rest and ST segment depression during chest pain did notoccur in this study. An increase of the peripheral and/or coronaryresistances due to EM could be the mechanism of the ischemicattack in patients with severe coronary lesions.     

辛伐他汀对稳定劳力型心绞痛合并高胆固醇血症患者心肌缺血的影响

目的　探讨辛伐他汀调脂治疗对稳定劳力型心绞痛合并高胆固醇血症患者运动诱发心肌缺血的影响。方法　选择运动试验阳性且血浆总胆固醇浓度增高的稳定劳力型心绞痛患者 90例 ,随机分为治疗组和对照组 ,治疗组给予辛伐他汀 12周 ,对照组仅予饮食控制 ,治疗前后行心电图运动试验 ,比较两组运动试验结果的差异。结果　①经 12周治疗后 ,治疗组血TC、TG、LDL C均显著降低 ,HDL C显著升高 (P <0 0 5) ,而对照组血脂各项指标的变化均无统计学意义。②辛伐他汀组治疗后运动耐量显著提高 ,运动试验阳性率明显降低 ,至ST段下移 1mm时间明显延长 ,ST段下移值显著减少 (P <0 0 5) ,而对照组治疗前后各项指标的变化均无统计学意义。结论　辛伐他汀治疗在降低血脂的同时 ,还可明显减轻稳定劳力型心绞痛合并高胆固醇血症患者运动诱发的心肌缺血     

Nocturnal angina in patients with fixed coronary stenosis. Increased coronary vasoconstrictive sensitivity with independence of pacing ischaemic threshold

Atrial pacing and ergonovine tests were performed in 18 consecutivepatients with unstable angina at rest and significant coronaryartery stenosis ( 90% in one vessel in 16 patients). 13 ofthem also had exertional angina. 14 patients presented at leastone positive response (1.0 mm ST-segment shift) to pacing, witha heart rate (144±11 vs 75±13 beats min^–1,P<0.001) and double product (195±26 vs 108±32x 10^–2 P<0.001) significantly higher than during anginaat rest. In the ten patients who presented nocturnal angina,the incidence of positive response to pacing and the pacingischaemic threshold, tested on three different days, were similarto those seen in the remaining patients. In contrast, the ergonovinetest was positive in all patients with nocturnal angina (100%),who required a low dose (0.28±0.2 mg), but it was positivein only four (50%) of those without nocturnal angina, who neededa higher dose (0.55±0.12 mg, P<0.005). Therefore, in patients with severe coronary stenosis and exertionalangina, spontaneous episodes, including nocturnal angina, arenot related to increases in heart rate. The increased coronaryvasoconstrictive sensitivity found in these patients, particularlythose with nocturnal angina, was not dependent on the statusof the coronary reserve, which strongly suggests that changesin coronary tone, focal or diffuse, are involved in the mechanismsof these ischaemic events.     

Ergonovine testing for coronary artery spasm in patients with angiographic mitral valve prolapse

Coronary artery spasm (CAS) has been postulated to be a pathophysiologic mechanism in the production of ischemic-like chest pain and ECG changes in patients with idiopathic mitral valve prolapse syndrome. To evaluate the possible role of symptomatic CAS evoked by ergonovine maleate, this agent was administered (0.05 to 0.4 mg IV) to 24 patients with chest pain and mitral valve prolapse who had no significant (<50%) coronary artery obstruction. Symptoms, ECG and blood pressure changes were monitored in all patients following ergonovine administration. No significant changes were observed in heart rate, systolic blood pressure, or double product. Six patients developed their typical chest pain. In two of these six with chest pain, ST segment shifts >1 mm were seen. Post-ergonovine left ventricular end-diastolic pressure (LVEDP) and coronary angiographic changes were also studied in a subgroup of 12 of these patients, including five of the six chest pain responders. In the five chest pain responders, pain was associated with a significant rise in LVEDP, whereas no significant change occurred in those patients not experiencing chest pain (p<0.01). Chest pain was also associated with significant CAS (>50% lumen reduction) in two patients, each with ST segment shifts >1 mm. In summary, ergonovine stimulation failed to evoke symptoms, ECG or blood pressure changes in three quarters of mitral valve prolapse patients studied. Six patients developed chest pain. Chest pain was associated with ECG changes characteristic of CAS in two of these patients, each with angiographic CAS. Thus, symptomatic CAS induced by ergonovine was absent in the majority of these 24 patients with idiopathic mitral valve prolapse syndrome.     

微血管性心绞痛临床特点研究

目的探讨微血管性心绞痛的临床特征。方法对30例具有典型心绞痛发作患者行常规心电图、24h动态心电图、平板运动试验检查及冠状动脉超影检查。结果静息心电图正常18例,有缺血性ST-T改变10例,冠状动脉造影正常30例,超声心动图正常28例。30例患者心绞痛发作时ST段压低,平板运动试验30例均阳性。结论微血管性心绞痛是由于冠脉微血管内皮功能障碍及微血管结构异常导致的心肌缺血。诊断需结合临床表现、心电图、平板运动试验及冠状动脉造影结果。治疗以硝酸酯类、β受体阻滞剂、尼可地尔疗效显著。临床预后良好。     

Temporal variability and correlation with geometric parameters in vasospastic angina: a quantitative angiographic study

Long-term changes in vasocontractility were examined in 23 coronarysegments from 20 patients with variant angina using computer-basedquantitative coronary angiography and ergonovine provocationtests repeated at an interval of 42 ± 14 months. Measurementsof vasospasticity at the sites of fixed stenoses were comparedwith values predicted by an elementary geometric theory basedon the assumption that the cross-sectional area of a vesselwall is constant regardless of its state of vasoconstriction.While all patients were symptomatic initially, only 11 remainedsymptomatic at follow-up. At the initial provocation test, theresponse was correctly predicted in four segments, was lowerthan expected in one, and was stronger in 18. At follow-up,only one of the four segments in which the response had beeninitially predicted correctly again showed the predicted responseand the remaining three showed a response weaker than expected;the one segment which was initially hypocontractile remainedhypocontractile at follow-up; and of the 18 segments which wereinitially hypercontractile, 12 exhibited hypercontractilityagain, four had the predicted value and the remaining two showedhypocontractility. In one one of 23 segments did the geometrictheory predict the behaviour of vasospasticity at the site offixed stenosis on both tests. Vasospastic responsiveness isa dynamic process demonstrating temporal variability and isnot directly predicted by geometric theory.     

尼可地尔对劳力型心绞痛病人运动耐力的影响

对１９例劳力型心痛病人给予尼可地尔口服２周，通过卧位踏车试验观运动心电图二尖瓣口多普勒血流变化。用药后Ｓ－５段下降消失时间，运动持续时间及运动工作负荷明显改善，静息及运动工作后Ａ／Ｅ比，Ｅ峰减时间及减速度明显改善，表明尼可地尔能改善冠心病人的左室舒张功能，提高运动耐力。     

Outcome of Unstable Angina in Patients with Diabetes Mellitus

This prospective hospital-based, case–control study compares the outcome of unstable angina in non-insulin dependent diabetic patients and non-diabetic control subjects. One hundred and sixty-two diabetic patients and 162 non-diabetic control patients with unstable angina were entered into the study. The 3-month mortality was 8.6 % (95 % confidence interval, CI = 4.4–12.9 %) in diabetic patients and 2.5 % (CI = 0.1–4.9 %) in control patients (p = 0.014). The 1-year mortality was 16.7 % (CI = 10.9 %–22.4 %) in diabetic patients and 8.6 % (CI = 4.4 %–12.9 %) in non-diabetic patients (p = 0.029). Diabetic patients received beta-blockade and underwent coronary angiography and angioplasty less frequently than controls; the frequency of unstable angina, of acute myocardial infarction, and of coronary artery bypass grafting was similar in both groups at 1 year of follow-up. It is concluded that diabetic patients with unstable angina have a higher mortality than non-diabetic patients and that this difference is largely accounted for by early (first 3 months) mortality. © 1997 by John Wiley & Sons, Ltd.     

Limitations of ergonovine testing in patients with variant angina

Fourteen patients with variant angina underwent ergonovine testing during diagnostic coronary angiography. The clinical electrocardiographic or angiographic manifestations of coronary artery spasm could not be reproduced in six of these patients. Five patients had chest pain and transient ST-segment elevation within 4 days of the ergonovine study, including three who developed coronary spasm in the catheterization laboratory. It appears that the sensitivity of ergonovine testing in the diagnosis of coronary spasm is lower than previously emphasized.     

Long lasting spasticity in controlled vasospastic angina

OBJECTIVE: To evaluate changes in coronary artery spasticity in patients with vasospastic angina who had been stable for years under continuous drug treatment. METHODS: Follow up coronary angiography was performed under intracoronary ergonovine provocation in 27 well controlled patients with vasospastic angina and no organic stenosis; the tests were done > 24 months after the initial coronary angiography, in which occlusive spasm had been induced by the same regimen of ergonovine provocation. RESULTS: The mean (SD) follow up period was 47.2 (21.6) months. All patients had been free from angina attack for more than 24 months under treatment with antianginal drugs. During this follow up period, organic stenosis developed in only one case. Occlusive spasm was observed during follow up coronary angiography in 23 patients. Spasm with 90% narrowing was observed in three other patients, and diffuse significant narrowing was seen in the final patient. No significant difference was found in spasticity (p = 0.75) between the initial and the follow up tests. CONCLUSIONS: Repeated ergonovine provocation during coronary angiography after a controlled period of several years showed that coronary spasm remains inducible in most patients. Discontinuance of drug treatment during the remission from anginal attacks achieved by medication may put the patient at high risk.     

Verapamil in effort-induced angina pectoris in patients with normal coronary arteries

Summary: Two patients with classical effort-induced angina pectoris associated with abnormal ST-segment depression on graded exercise testing and normal coronary arteriograms are described. Both patients deteriorated during treatment with propranolol, and became asymptomatic during treatment with verapamil with normal graded exercise tests. Verapamil may thus improve an inadequate vasodilatatory response of the coronary vascular bed to effort.     

变异性心绞痛患者并发晕厥的相关因素分析

目的分析变异性心绞痛患者伴发晕厥的相关危险因素。方法 2003年1月至2011年03月期间我院心内科住院患者中诊断变异性心绞痛74例,根据病程中晕厥发作的有无,分为晕厥组（n=16）和非晕厥组（n=58）。对比分析两组患者的危险因素、临床特征和冠状动脉造影结果。结果 （1）与非晕厥组比较,晕厥组患者发作时恶性心律失常发生率较高（10.3%对100%,P〈0.0001）,空腹血浆低密度脂蛋白胆固醇较低（2.15±0.73mmol/L对1.68±0.45mmol/L,P=0.003）,两组患者的心血管危险因素、胸痛特点和入院前使用药物、其他实验室检查指标、左室射血分数、发作时心电图的心脏缺血部位和ST段抬高导联数目并无统计学差异。（2）冠脉造影显示,两组患者的血管病变严重程度无统计学差异;与非晕厥组比较,晕厥组患者中前降支固定性狭窄较少（34.48%对6.25%,P=0.03）,而右冠狭窄较多,但未达统计学差异（8.62%对25%,P=0.095）。（3）多因素Logistic回归分析显示恶性心律失常（P〈0.0001）和右冠状动脉狭窄（P=0.028）是变异性心绞痛患者发生晕厥的独立危险因素。结论变异性心绞痛患者并发晕厥并非少见,恶性心律失常是晕厥的直接原因。右冠状动脉固定性狭窄的患者容易发生晕厥,需要引起重视并积极干预。     

国产辛伐他汀对不稳定型心绞痛患者血浆C反应蛋白的影响

目的　研究京必舒新对不稳定型心绞痛患者血浆C反应蛋白 (CRP)的水平的影响。方法　 60例不稳定型心绞痛 (unstableanginaUA)病人随机分为治疗组与对照组 ,治疗组除用UA常规治疗外加用京必舒新 2 0mg每晚口服 ,对照组仅给予UA常规治疗。比较两组病人治前及经治后 2周、4周、8周的血浆CRP。结果　治疗组自 2周始CRP水平即开始下降 ,4周及 8周的CRP水平较治疗前出现显著差异 (P <0 .0 1) ;对照组治疗前、后的CRP水平未见明显变化(P >0 .0 5 )。结论　京必舒新可显著降低UA病人的血浆CRP浓度。     

不稳定性心绞痛的临床特点和冠状动脉造影结果分析

对８２例不稳定性心绞痛患者进行回顾性研究。结果表明：该病多见于老年男性（占８６．６％）。高血压、高胆固醇血症、糖尿病、吸烟、饮酒史、冠心病家族史和高血压（或）脑血管病家族史均是其危险因素，分别占６３．４％、３６．６％、２２．０％、８２．９％、３４．１％、３４．１％和７０．７％。冠状动脉造影病变部位最多见于前降支（占８４．１％）。其次为右冠脉（占４８．８％），左旋支（占３２．９％），左冠脉主干（占６．１％），其中Ⅲ—Ⅴ级病变占７６．６％，７７．３％为偏心性狭窄。初发劳力型心绞痛８５．７％为单支病变，自发型心绞痛５０％为Ⅰ－Ⅱ级病变，且有４例冠脉造影结果大致正常，９６．３％的恶化劳力型心绞痛，８４．６％的梗塞后心绞痛为多支病变。９例有室壁瘤形成，既往均有心肌梗塞病史。