Acetylcholine Use in Modern Cardiac Catheterization Laboratories: A Systematic Review

Abstract

Background: The use of acetylcholine for the diagnosis of vasospastic angina is recommended by international guidelines. However, its intracoronary use is still off-label due to the absence of safety studies. We aimed to perform a systematic review of the literature to identify adverse events related to the intracoronary administration of acetylcholine for vasoreactivity testing to fill this gap. Methods and results: We conducted a systematic review of observational studies and randomized controlled trials dealing with the intracoronary administration of acetylcholine. Articles were searched in MEDLINE (PubMed) using the MeSH strategy. Three independent reviewers determined whether the studies met the inclusion and exclusion criteria. A total of 434 articles were selected. Data concerning clinical characteristics, study population, acetylcholine dosage, and adverse effects were retrieved from the articles. Overall, 71,566 patients were included, of which only 382 (0.5%) developed one adverse event, and there were no fatal events reported (0%). Conclusions: Intracoronary administration of acetylcholine in the setting of coronary spasm provocation testing is safe and plays a central role in the evaluation of coronary vasomotion disorders, making it worthy of becoming a part of clinical practice in all cardiac catheterization laboratories.

Contemporary Diagnosis and Management of Patients with MINOCA

“…Provocative coronary functional testing can evaluate vasospasm due to suspected coronary microvascular dysfunction (CMD) and epicardial coronary vasospasm [31]. Acetylcholine infusion with epicardial vasospasm visualization on coronary angiography is the reference gold standard test to diagnose coronary epicardial vasospasm [43][44][45].…”

“…A meta-analysis with 71,566 patients with ischemia with nonobstructive coronary arteries (INOCA) reported the incidence of complications after acetylcholine infusion to be 0.5%, with no reported deaths [47]. Complications included ventricular fibrillation or tachycardia in 0.2%, atrial fibrillation in 0.1%, transient bradycardia or advanced atrioventricular block in 0.1%, and prolonged refractory spasm without MI in 0.1% [43]. Additionally, the incidences of arrhythmias with acetylcholine in MINOCA, INOCA, and after spontaneous vasospasms were similar [44,47].…”

“…Several studies suggest that provocative testing during index hospitalization or by referral to capable facilities can be beneficial for the following reasons. First, a positive provocative test in MINOCA is safe, and arrhythmias are rare [43,47,48]. Second, it can further help identify MINOCA patients with poor outcomes [32,47].…”

“…Provocative coronary functional testing can evaluate vasospasm due to suspected coronary microvascular dysfunction (CMD) and epicardial coronary vasospasm [ 31 ]. Acetylcholine infusion with epicardial vasospasm visualization on coronary angiography is the reference gold standard test to diagnose coronary epicardial vasospasm [ 43 – 45 ]. Ong et al reported in the CASPAR study that up to 50% of patients with MINOCA had coronary vasospasm after acetylcholine infusion, [ 46 ] and many studies suggest this test is well tolerated in MI [ 32 , 44 , 47 ].…”

Role of Intracoronary Imaging in Myocardial Infarction with Non-Obstructive Coronary Disease (MINOCA): A Review

“…The frequency of major complications in intracoronary infusion of vasoactive agents according to Ciliberti’s observational study ranges from 0% to 4.9%, while the rate of minor complications ranges from 0% to 16.3% [ 70 ]. The most common major complication is ventricular fibrillation (VF) or sustained ventricular tachycardia (SVT) occurring in 0.69% of the cases, while shock (0.03%), myocardial infarction (0.01%), and prolonged/refractory spasm (0.01%) are rare [ 65 ].…”