Recently, ergonovine has been suggested to evoke coronary artery spasm in patients with variant angina. The purpose of our investigation was to study clinical, hemodynamic, electrocardiographic (ECG), and coronary angiographic effects of ergonovine in 60 selected patients undergoing angiography. The patients were equally divided, 30 with coronary artery disease (CAD), lesions 250%, and 30 with minimal (<50%) or no CAD. Ergonovine (0.05 to 0.4 mg i.v. bolus) was given while each patient was monitored for symptoms and changes in ECG, heart rate, QTc intervals, blood pressure, and coronary diameter. After ergonovine, 18 patients developed chest pain, eight of whom had associated STsegment shifts (>-I mm). Heart rate and QTc showed no significant change. Systolic blood pressure increased from 133 mm Hg (mean) to
SUMMARY Ergonovine has been shown to provoke attacks of variant angina, but a question remains whether spontaneous and ergonovine-induced attacks of variant angina are similar. Seven patients with variant angina undergoing cardiac catheterization were studied during transient episodes of spontaneous and ergonovine-induced rest angina with ST-segment elevation. Clinical, electrocardiographic, left ventricular hemodynamic and coronary angiographic observations were made before and repeated after ergonovine (0.05 -0.2 mg I.V.). The character and duration of chest pain were similar during both spontaneous and ergonovineinduced episodes. ST-segment elevation (> 1 mm) was present inferiorly in three patients, anteriorly in three patients, and both inferiorly and anteriorly in one patient during both episodes. Mean heart rate and systolic arterial pressure changed little, while left ventricular end-diastolic pressure increased significantly during spontaneous or ergonovine-induced attacks. We observed subtotal or total dynamic obstruction in the left anterior descending (three patients), right coronary arteries (three patients) and both arteries in one patient during both attacks. Thus,-in selected patients ergonovine-induced attacks of variant angina were remarkably similar to spontaneous episodes. In this paper we present evidence that clinical, electrocardiographic, left ventricular hemodynamic and coronary angiographic changes during ergonovine-induced attacks of variant angina are remarkably similar to spontaneous episodes. Patient Selection and Methods Patient SelectionOver 18 months 18 patients with the clinical syndrome of variant angina defined as cyclic rest angina with ST-segment elevation were studied at cardiac catheterization. Seven of these patients were studied during spontaneous chest pain and during pain provoked by ergonovine administration. Findings from these patients are the basis of this report. ProtocolBefore study each patient signed a written informed consent after a full explanation of the risks of cardiac catheterization and ergonovine testing. Our criteria for patient selection and exclusion from ergonovine testing have been previously reported'." After an overnight fast and without premedication patients underwent combined heart catheterization and angiography using standard techniques.15 16 During episodes of spontaneous pain, ECGs and left ventricular pressures were recorded, followed by selective angiography. When possible both coronary arteries were studied during episodes of pain. The coronary artery supplying the region of the heart showing ST-segment elevation was injected first. If the patient remained stable with respect to blood pressure and rhythm, the catheter was repositioned in the other artery and selective coronary angiograms were repeated. After resolution of chest pain and ST-segment shifts without administering nitroglycerin, repeat coronary angiography was performed. Ergonovine maleate (Ergotrate, Eli Lilly Co) was then given intravenously in divided doses. Bolus doses...
exercise in the diagnosis of presence and extent of coronary heart disease. Br Heart J 35: 1321, 1973 25. Sharma B, Taylor SH: Localization of left ventricular ischemia in angina pectoris by cineangiography during exercise. Br Heart J 37: 963, 1975 26. Hamilton GW, Williams DL, Gould KL: Selection of appropriate frame rates for radionuclide angiography. (abstr) J DL: Myocardial imaging with Thallium-201 at rest and during exercise. Comparison with coronary arteriography and resting and stress electrocardiography. Circulation 56: 66, 1977 31. Bailey IK, Griffith LSC, Rouleau J, Strauss HW, Pitt B: Thallium-201 myocardial perfusion imaging at rest and during exercise. Comparative sensitivity to electrocardiography in coronary artery disease. Circulation 55: 79, 1977 32 Botvinick EH, Taradash MR, Shames DM, Parmley WW: Thallium-201 myocardial perfusion scintigraphy for the clinical clarification of normal, abnormal and equivocal electrocardiographic stress tests.SUMMARY The effect of ergonovine on left ventricular hemodynamic and lactate-pyruvate measurements was studied in twenty-six patients. Patients were divided into two groups: Group 1 (seven patients) had a welldocumented variant angina syndrome and Group 2 (19 patients) had other chest pain syndromes. Ergonovine was given as the following were evaluated: symptoms, electrocardiographic changes, left ventricular pressure, myocardial lactate-pyruvate metabolism and coronary artery diameter changes. Chest pain and ST elevation occurred following ergonovine in all seven Group 1 patients. Left ventricular end-diastolic pressure increased (14-26 mm Hg mean, P < 0.05) and lactate extraction decreased (24% to -7%, P < 0.05). Subtotal or total dynamic obstruction of a major coronary artery occurred in each of the six Group 1 patients in whom coronary angiography was repeated during pain. In each case the location of ST elevation corresponded to the area perfused by the dynamically obstructed vessel. In Group 2 following ergonovine 13 patients remained asymptomatic, while six developed chest pain without ST changes. Left ventricular systolic and end-diastolic pressure increased (126-138 mm Hg and 14-17 mm Hg mean, respectively, both P < 0.05) associated with a minimal diffuse coronary vasoconstriction. Lactate-pyruvate metabolism remained unchanged. No differences were noted between Group 2 patients with and without chest pain following ergonovine. Thus, only in patients with documented variant angina did ergonovine induce chest pain with ST elevation associated with hemodynamic and metabolic evidence for myocardial ischemia concomitant with subtotal or total dynamic coronary artery narrowing. In other patients only minimal generalized coronary vasoconstriction without metabolic evidence for myocardial ischemia occurred following ergonovine, regardless of the presence or absence of chest pain.HEMODYNAMIC CHANGES during spontaneous chest pain with ST elevation, reported by Guazzi et al.,1 2 Gaasch et al.3 and Maseri et al.,4 include a fall in dp/dt, cardiac output and sy...
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 (less than 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 shift greater than 1 mm were seen. Post-ergonovine left ventricular end-diastolic pressure (LVEDP) and coronary angiographic changes were also studied in 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 less than 0.01). Chest pain was also associated with significant CAS (greater than 50% lumen reduction) in two patients, each with ST segment shifts greater than 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 assoicated 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.
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