Intermittent coronary spasm during graded exercise.

We report a patient with Prinzmetal's angina with nearly normal coronary angiogram who not only developed severe myocardial ischemia during exercise, documented both electrocardiographically (ST elevation) and scintigraphically (with thallium-201), but also did so intermittently as the graded exercise progressed. Diagnostic coronary angiography showed spontaneous focal spasm of the proximal left anterior descending coronary artery. This unique response to exercise in a patient with variant angina suggests that factors other than catecholamine stimulation alone are active and rapidly attenuated in some patients. This phenomenon could be overlooked without appropriate electrocardiographic monitoring.     

Sudden Cardiac Arrest at the Finish Line: In Coronary Ectopia,the Cause of Ischemia Is from Intramural Course,Not Ostial Location

A 26-year-old woman, a well-trained runner, had a sudden cardiac arrest just before crossing the finish line of a marathon. She was rapidly resuscitated and was later found to have an ectopic origin of the left coronary artery. This anomaly was surgically repaired by translocating the ostium from the right to the left sinus of Valsalva. Her difficult postoperative course prompted further coronary evaluation, which revealed severe stenosis of the neoostium. The patient underwent a second operation: this time, the stenosis was bypassed via a left internal mammary artery-to-left anterior descending coronary artery (LAD) graft. Hypoplasia of the LAD and spasm during manipulation caused the graft to fail, necessitating double-stent angioplasty of the left main ostium and the LAD 2 months later. At the patient''s 6-month follow-up examination, she had no further evidence of functional ischemia, and she resumed jogging.Because the mode and mechanism of the patient''s condition and events were documented in unusual detail, this case furthers our understanding of sudden cardiac arrest in athletes who have rare coronary anomalies. We conclude that ectopia of a coronary artery does not itself cause potentially fatal ischemia. Rather, these events are due to the ectopic artery''s intramural proximal course within the aortic media, which might result in critical stenosis by means of hypoplasia or lateral compression of the artery.     

Managing Thrombosis and Hemorrhage in a Man with Myocardial Infarction and Traumatic Hemopericardium with Cardiac Tamponade

A 79-year-old man had an out-of-hospital acute ST-segment-elevation myocardial infarction with cardiac arrest. Cardiopulmonary resuscitation performed by a bystander resulted in traumatic hemopericardium. We discuss the patient''s case, highlight the challenges of managing simultaneously life-threatening thrombosis and hemorrhage, and present our conclusions regarding the patient''s eventual death.     

Pathophysiology of the Syndrome: Biventricular Takotsubo Cardiomyopathy: Case Report and General Discussion

In recent years, our understanding of the physiologic mechanisms of transient takotsubo cardiomyopathy has improved because of the growing use of emergent heart catheterization in patients who present with severe ischemic syndromes. However, even this procedure has revealed only that, in most patients with takotsubo syndrome, the sudden onset of ventricular dysfunction is not due to fixed coronary artery occlusions. We present a case of transient takotsubo cardiomyopathy with an exceptional feature—uneven impairment of both right and left ventricular function, or biventricular takotsubo—and we discuss a novel, comprehensive theory that we have devised to explain the pathophysiology of this syndrome''s many manifestations.Key words: Acetylcholine/diagnostic use, angina pectoris, variant, coronary endothelial dysfunction, coronary vasospasm/physiopathology, takotsubo cardiomyopathy/classification/diagnosis/physiopathology, ventricular dysfunction, left/etiology/diagnosis, ventricular dysfunction, right/etiology/diagnosisOnly during the last 2 decades have Japanese authors^1,2 specifically categorized transient takotsubo cardiomyopathy (TTC) as an entity in itself. Before that time, TTC was often called “acute myocardial infarction with normal coronary arteries.”³ Its prevalence is probably as low today as in the remote past. However, acute coronary artery syndromes are now studied aggressively with emergent heart catheterization, which documents better than any previous means the transience of the myopathy and the presence of apparently normal coronary arteries. These circumstances have stimulated the quest to generate a pathophysiologic concept broad enough to encompass the full clinical spectrum of TCC.Apical ballooning (resulting in a systolic takotsubo or “octopus trap”) is the most frequent and emblematic feature of TTC. The use of this term has successfully promoted awareness of the disease in the cardiology community at large, but it has also impeded clinicians'' understanding of the breadth of this entity''s clinical manifestations. Our persistently inadequate knowledge of the nature and spectrum of TTC seems to warrant an update on the subject.Here, we present a case of right ventricular (in union with left ventricular) TTC. In addition, we discuss a pathophysiologic theory that our group has recently proposed, which might explain the newly discovered and broad spectrum of TTC clinical manifestations.     

Comparison of clinical and laboratory findings between patients with diffuse three-vessel coronary artery spasm and other types of coronary artery spasm

Our purpose was to compare patients with diffuse three-vessel coronary artery spasm and other types of coronary artery spasm without significant organic stenosis, and to elucidate clinical characteristics and risk factors. Patients were divided into two groups: group I consisted of 26 patients showing other types of coronary artery spasm; group II consisted of 5 patients with diffuse three-vessel coronary artery spasm. The mean age of patients in groups I and II was 52 and 50 years, respectively. The incidence of variant angina was higher in men than in women. The incidence of smoking was high in each group, but not significantly different. Exercise tests showed no significant differences between groups. All mean values of laboratory data, including lipoprotein (a) and low-density lipoprotein cholesterol in the two groups, were within normal ranges. There was no significant difference between groups. The incidence of spontaneous spam was much higher in patients with diffuse three-vessel coronary artery spasm (P < 0.01). Electrocardiographic (ECG) findings before the spasm were almost normal. All 5 patients with diffuse three-vessel coronary artery spasm demonstrated no important ST segment changes with episodes of angina during a coronary angiography on 12-lead ECG, compared to patients with other types of coronary artery spasm (P < 0.01). First, we conclude, diffuse three-vessel coronary artery spasm mostly occurs spontaneously. Second, we emphasize that diffuse three-vessel coronary artery spasm must be considered when 12-lead ECG shows no important ST segment changes with episodes of angina. Third, it is not easy to distinguish diffuse three-vessel coronary artery spasm from other types of coronary artery spasm on the basis of history, laboratory data, or electrocardiographic findings, including exercise tests. © 1996 Wiley-Liss, Inc.     

Coronary microvascular spasm triggers transient ischemic left ventricular diastolic abnormalities in patients with chest pain and angiographically normal coronary arteries

Aims

Impaired coronary microvascular dilatory function can lead to exercise induced myocardial ischemia and angina pectoris even in patients without significant (>50%) obstructive coronary atherosclerosis (APWOCA). Diffuse distal vessel epicardial spasm and microvascular spasm have been also proposed as a plausible explanation for angina at rest in these patients. However, objective systematic evidence for the latter i.e. echocardiographic wall motion abnormalities during angina, is lacking at present. Coronary epicardial and microvascular spasm can be triggered in susceptible patients by the administration of intracoronary acetylcholine (Ach). We sought to assess whether Ach induced diffuse distal epicardial coronary artery spasm (≥75% diameter reduction) and coronary microvascular spasm can cause transient ischemic left ventricular dysfunction, as assessed by echocardiography.

Methods

50 patients (19 men aged 60.5 ± 8.9 years) with stable APWOCA were assessed for coronary spasm and myocardial ischemia with intracoronary Ach infusion, 2D transthoracic echocardiography (before and during Ach testing), continuous 12-lead ECG monitoring, and ultrasensitive cardiac troponin (US-cTn) measurement before and within 4 h after Ach testing.

Results

14 patients (28%) had a “negative” Ach test, 14 (28%) developed coronary microvascular spasm and 17 (34%) had diffuse distal epicardial spasm. In 5 patients (10%) the test was inconclusive. Echocardiographic variables including deceleration time, EF slope and E/A, as well as ultrasensitive-cTn concentrations were abnormal during Ach induced ischemic ECG changes. Conclusions: We have, for the first time, demonstrated that Ach induced coronary microvascular spasm is associated with echocardiographic changes and ultrasensitive-cTn elevations, indicative of myocardial ischemia.     

Guide catheter exchange

The role of coronary vasoconstriction in acute myocardial infarction is controversial. Two patients are presented who were studied with angiography during the early hours of acute myocardial infarction and in whom reversible spasm of non-infarct vessels was observed. A tendency towards coronary vasospasm may be a generalized phenomenon during acute myocardial infarction. © 1995 Wiley-Liss, Inc.     

Coronary Artery Spasm in Multivessel ACS: What More Should We Know?

Coronary spasm may present as acute coronary syndrome (ACS), “which can be an ST segment elevation myocardial infarction (STEMI), non-STEMI, or unstable angina.” However, the prevalence of coronary spasm in patients with ACS remains unknown due to scarcity of data. Concomitant coronary spasm may mask the true atherosclerosis burden in such cases, posing several management challenges. We illustrate the case of managing an ACS patient with concomitant spasm and atherosclerotic disease. We show that the routine use of vasodilator treatment in ACS cases may prevent inappropriate stenting by identifying concomitant coronary spasm, influencing the clinical outcomes associated with inappropriate stenting in the setting of coronary spasm.     

Coronary artery blood flow: physiologic and pathophysiologic regulation

Acute myocardial ischemia, which results from a significant imbalance between myocardial oxygen demands and myocardial oxygen supply, occurs in as many as six million persons with atherosclerotic coronary artery disease in the United States. Accordingly, a clear understanding of the physiologic and pathophysiologic factors that influence coronary artery blood flow is important to the clinician and provides the basis for the judicious use of medications for the treatment of patients with atherosclerotic coronary artery disease. This review discusses the endothelial, metabolic, myogenic, and neurohumoral mechanisms of coronary blood flow regulation and the interaction of the different mechanisms in the regulation of coronary blood flow. The importance of nitric oxide in coronary blood flow regulation is emphasized. We also discuss the common clinical problems of hyperlipidemia and coronary atherosclerosis, coronary artery spasm, and systemic arterial hypertension that result in coronary artery endothelial dysfunction, the impaired production and increased inactivation of nitric oxide, and impairment in coronary blood flow regulation. This information is important to clinicians because more than forty million people in the United States have atherosclerotic or hypertensive heart disease and therefore are at risk for significant myocardial complications due to impairment of coronary blood flow regulation.     

硫氮酮治疗经皮腔内冠状动脉成形术中冠状动脉痉挛的效果

目的探讨急性心肌梗死患者经皮腔内冠状动脉成形术中冠脉内注射硫氮艹卓酮治疗冠脉痉挛的效果。方法39例术中发生冠脉痉挛病例,分别注射硫氮艹卓酮和硝酸甘油并进行比较。结果硫氮艹卓酮组20 s、40 s痉挛缓解率分别为85%、15%,总缓解率100%;硝酸甘油组20 s、40 s缓解率79%、11%,总缓解率89%,两组比较无显著差异。冠状动脉内应用硫氮艹卓酮1、3、5和10 m in心率、动脉血压无显著变化。结论冠脉内注射硫氮艹卓酮和硝酸甘油能同样有效地缓解AM I患者行PTCA中发生的冠脉痉挛,并且无严重的负性变时和降压作用。     

Association Between Morning Surge in Systolic Blood Pressure and SYNTAX Score I in Patients With Stable Coronary Artery Disease

A high morning surge in systolic blood pressure poses a risk in people who have cardiovascular disease. We investigated the relationship between this phenomenon and the SYNTAX score I in patients who had stable coronary artery disease.Our single-center study included 125 consecutive patients (109 men and 16 women; mean age, 54.3 ± 9 yr) in whom coronary angiography revealed stable coronary artery disease. We calculated each patient''s sleep-trough morning surge in systolic blood pressure, then calculated the SYNTAX score I.The morning surge was significantly higher in patients whose score was >22 (mean, 22.7 ± 13.2) than in those whose score was ≤22 (mean, 12.4 ± 7.5) (P <0.001). Forward stepwise logistic regression analysis revealed that morning surge in systolic blood pressure was the only independent predictor of an intermediate-to-high score (odds ratio=1.183; 95% CI, 1.025–1.364; P=0.021).To our knowledge, this is the first study to show an association between morning surge in systolic blood pressure and the SYNTAX score I in patients who have stable coronary artery disease.     

Coronary vasospasm produces reversible perfusion defects observed during adenosine triphosphate stress myocardial single-photon emission computed tomography

BACKGROUND: Adenosine triphosphate stress thallium-201 single-photon emission computed tomography (ATP-SPECT) is useful for diagnosing coronary artery disease (CAD), although sometimes false positive results are observed. It has not been established whether a coronary spasm is responsible for the false positive findings during ATP-SPECT. HYPOTHESIS: We investigated whether coronary spasm is one of the factors which produces reversible defects on ATP-SPECT. METHODS: Eighty-six patients (mean age: 62 y; 58 men) who underwent both spasm-provocation testing by coronary angiography and ATP-SPECT, were selected for the study. Patients with coronary narrowing (>30%), myocardial infarction, or heart failure were excluded. Patients were divided into 2 groups based on whether the spasm-provocation test result was positive (vasospastic angina [VSA] group, n = 46) or negative (non-VSA group, n = 39). RESULTS: The body mass index was lower in the VSA group than in the non-VSA group (p = 0.005). On ATP-SPECT imaging, any type of reversible defect was observed more frequently in the VSA group (68%) than in the non-VSA group (36%, p = 0.0027). Logistic regression analysis demonstrated that the presence of reversible defects was one of the factors accounting for the presence of coronary vasospasm (p = 0.0022, R2 = 0.172). CONCLUSIONS: The findings suggest that reversible defects on ATP-SPECT imaging are frequently present in patients with coronary vasospasm. Coronary spasm may be considered as 1 of the factors, which produce reversible defects on ATP-SPECT, observed in patients with chest symptoms and angiographically normal coronary arteries.     

Atypical ST-Segment-Elevation Myocardial Infarction Presentation in Patients With COVID-19 at a High-Volume Center in New York City

Atypical presentations of ST-segment-elevation myocardial infarction (STEMI) have been reported in patients who have COVID-19. We have seen this occurrence in our center in Bronx, New York, where multitudes of patients sought treatment for the coronavirus. We studied the prevalence of atypical STEMI findings among patients with COVID-19 who presented during the first 2 months of the pandemic.Consistent with previous reports, 4 of our 10 patients with COVID-19 and STEMI had no identifiable culprit coronary lesion; rather, they often had diffuse ST-segment elevations on surface electrocardiograms along with higher levels of D-dimer and inflammatory markers. In contrast, 32 of 33 patients without COVID-19 (97%) had a culprit lesion. The patients with COVID-19 and a culprit lesion more often needed thrombectomy catheterization and administration of glycoprotein IIb/IIIa inhibitors.Our study confirms that patients with COVID-19 often have atypical STEMI presentations, including the frequent absence of a culprit coronary lesion. Our findings can help clinicians prepare for these atypical clinical presentations.     

Transmural myocardial ischemia due to slow coronary flow

Slow coronary flow phenomenon(SCFP) is an angiographic observation characterized by delayed distal vessel opacifi-cation in the absence of significant epicardial coronary disease. Only limited studies have been focused on the etiologies,clinical manifestations and treatment of this unique angiographic phenomenon. In our case report,we described an 85-year-old man who came with significant ST segment elevation in leads V1-V4 and V3R-V5R without increase in myocardial enzyme. The patient also developed respiratory failure requiring intubation and mechanical ventilation. Coronary angiography revealed only mild atherosclerosis without spasm or thromboembolic occlusion. Slow flow was seen in all coronary arteries,especially in the left anterior descending and right coronary arteries. This case speculated that transmural myocardial ischemia with ST segment elevation might be resulted from slow coronary flow. Transmural myocardial ischemia can occur owing to abnormalities of the coronary microcirculation.     

The link between intracranial haemorrhage and cardiogenic shock: a case of Takotsubo cardiomyopathy

Myocardial dysfunction occurs frequently during subarachnoid haemorrhage (SAH) and it is often referred to as neurogenic stunned myocardium (NSM). Takotsubo cardiomyopathy (TTC), which can lead to life-threatening acute heart failure, has been considered a possible complication of SAH. Actually, NSM and TTC are believed to share the same pathophysiological mechanisms and are likely a manifestation of the same disease. We report a case of a 64-year-old woman with SAH and cardiogenic shock due to acute left ventricular dysfunction. Echocardiography and ventriculography showed the typical pattern of TTC. Angiography excluded coronary artery disease or coronary spasm. Short-term inotropic support was necessary. Rapid recovery of left ventricular function was observed after 8 days. Acute myocardial dysfunction due to TTC in the setting of SAH may lead to cardiogenic shock which is difficult to treat. Patients with SAH and haemodynamic instability warrant a careful assessment of ventricular function on admission to rule out TTC     

The provocation of coronary arterial spasm in patients with recent transmural myocardial infarction

Provocative tests for coronary spasm were performed in a groupof 131 patients (124 men and 7 women) with recent (<6 weeks)transmural myocardial infarction. Coronary arteriography wasperformed 27±9 days after the onset of the infarction.The provocative test was performed using a single IV bolus of0.4 mg of ergometrine. Aortic pressure, ECG and arteriogramsof the two coronary vessels were repeated 3 and 5 min later.Provoked spasm was observed in 27 (21%) of the patients. In13 (48%) the coronary spasm occurred in a vessel presumed tobe responsible for the myocardial infarction, while it was observedin coronary artery unrelated to the area of the infarct in 14(52% of the cases with spasm). Thus, this study demonstratesa high degree of reactivity of the coronary tree of patientswith recent transmural myocardial infarction suggesting thelikelihood of a role for spasm in the infarction process andoffering some explanation for subsequent recurrent ischemicevents.     

Spontaneous Multivessel Coronary Spasm During Diagnostic Coronary Angiography

Acute vasospastic angina, formerly known as Prinzmetal angina, is characterized by transient electrocardiographic changes that are not related to exertion. Its atypical presentation makes it difficult to establish the diagnosis, so it is probably underrecognized and therefore mismanaged. We treated a 49-year-old woman who presented with a 2-day history of chest pain associated with palpitations. Abnormal radionuclide stress test results prompted diagnostic coronary angiography, during which the patient reported chest pain and became hemodynamically unstable. Active coronary vasospasm at multiple sites was treated with intracoronary nitroglycerin and nicardipine, leading to immediate recovery.Our case highlights the importance of accurate, timely diagnosis of vasospastic angina, and of early recognition and management of spontaneous coronary spasm during angiography.     

Role of coronary spasm in the genesis of myocardial infarction: Study of a case treated by isosorbide dinitrate in situ then by transluminal angioplasty

We report the observation of a 62-year-old patient who was admitted for unstable angina. A prolonged chest pain (more than two hours) with a major electrocardiographic lesion in the posterior leads needed an urgent coronary arteriography in order to attempt a recanalization. Antecedents of arteriopathy of the lower limbs with aortobifemoral bypass required an axillary artery right side approach. A selective right coronary opacification showed complete occlusion at the junction of segments 1 and 2. An intracoronary injection of isosorbide dinitrate relieved a coronary spasm and allowed a complete visualization of the right coronary artery. This appeared to be very atherosclerotic with several severe narrowings, and a subocclusive lesion at the site of the initial occlusion. Percutaneous transluminal coronary angioplasties (PTCA) were performed and led to a real ‘restructuring’ of the right coronary artery. The clinical outcome was excellent without recurrent angina pectoris. An angiographic control performed 6 months after PTCA demonstrated the persistence of the coronary recanalization and an evident improvement of the segmental contractility. This report emphasizes the role of coronary spasm in the genesis of my-cardial infarction and shows that PTCA may be performed as a first approach at the acute phase of myocardial infarction; to our knowledge it is the first PTCA performed by an axillary approach at the acute stage of myocardial infarction.