Clinical observation of spontaneous anginal attacks and multivessel spasm in variant angina pectoris with normal coronary arteries: Evaluation by 24-hour 12-lead electrocardiography with computer analysis

Onaka, Haruhiko; Hirota, Yuzo; Shimada, Satoshi; Kita, Yoshio; Sakai, Yasuhiko; Kawakami, Yoshihide; Suzuki, Shuji; Kawamura, Keishiro

doi:10.1016/0735-1097(95)00423-8

Cited by 59 publications

(39 citation statements)

References 29 publications

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“…[4][5][6] The attacks are severe and are accompanied by syncope, inferior ST-segment elevation and transient AV block, suggestive of acute transient occlusion of the RCA, a frequent site in Prinzmetal angina. 7 Coronary angiography showed a single non-critical obstruction in the distal part of the RCA. Intuitively we held spasm at this site responsible for the attacks, but later we realised that spasm may develop at sites other than the fixed lesion.…”

Section: Discussionmentioning

confidence: 99%

Multifocal spasm with acetylcholine in Prinzmetal angina

Michels¹,

Baars²

2008

NHJL

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A 60-year-old female patient with Prinzmetal angina and a single non-critical (<50%) focal obstruction in the right coronary artery was referred for percutaneous coronary intervention. Coronary angiography with provocative testing using incremental doses of acetylcholine demonstrated diffuse mild vasoconstriction and multifocal hyperreactive vasoconstriction in apparently normal coronary segments but not at the site of the nonsignificant obstruction. We refrained from intervention and advised avoidance of β-blockade, and continuation of medical therapy with nitrates and calcium antagonists. (Neth Heart J 2008;16: 134-6.)Keywords: Prinzmetal angina, acteylcholine, multifocal spasm A 60-year-old female was awakened early one morning with extreme chest discomfort radiating to both her arms. She felt weak and light-headed and she fainted when she tried to get up. She regained consciousness quickly without sequelae. Upon arrival at the hospital she was without symptoms. The ECG was normal. Physical examination revealed no abnormalities. During her hospital stay she had two more early morning episodes of chest discomfort with inferior ST-segment elevation and second degree as well as complete AV block (figure 1). She is a cigarette smoker with no other classical risk factors. Coronary angiography in the absence of ischaemia revealed a normal left coronary artery and a mild fixed coronary obstruction in the distal segment of the right coronary artery (RCA). The diagnosis of Prinzmetal angina was made. 1 She was treated with calcium antagonists and nitrates. She was referred for percutaneous coronary intervention (PCI) of the non-critical obstruction ( figure 2A), but we decided to perform a provocative test with selective intracoronary infusions of acetylcholine in incremental doses. 2 Infusion of acetylcholine at the third dose level (50 µg) induced diffuse mild vasoconstriction and multifocal hyperreactive vasoconstriction (spasm) in apparently normal coronary segments but not at the site of the alleged culprit lesion (figure 2B). The mild constriction and spasms were promptly resolved by intracoronary nitroglycerin ( figure 2C). We refrained from PCI and advised an intensification of the therapy with calcium antagonists, nitrates, aspirin and statins, and avoidance of β-blockade and smoking. DiscussionThis patient presented with classical Prinzmetal (variant) angina. She is a cigarette smoker with no other classical risk factors. 3 As with acute myocardial infarction, a circadian periodicity is present with attacks recurring at approximately the same time in the 24-hour period. [4][5][6] The attacks are severe and are accompanied by syncope, inferior ST-segment elevation and transient AV block, suggestive of acute transient occlusion of the RCA, a frequent site in Prinzmetal angina. 7 Coronary angiography showed a single non-critical obstruction in the distal part of the RCA. Intuitively we held spasm at this site responsible for the attacks, but later we realised that spasm may develop at sites other than the fixed...

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Section: Discussionmentioning

confidence: 99%

Multifocal spasm with acetylcholine in Prinzmetal angina

Michels¹,

Baars²

2008

NHJL

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“…When coronary arteriogram is normal or shows only nonobstructive plaques and if transient ST-segment elevation can be demonstrated in association with discomfort, the diagnosis of Prinzmetal's angina can be made and no further tests are necessary [2,3,5]. A 24-h ambulatory ECG may be helpful in demonstrating ST-segment elevation [2,3,8,9]. According to Onaka et al [9], 22 of 30 patients (73%) with diagnosed variant angina demonstrated ST-segment elevation during monitoring.…”

Section: Discussionmentioning

confidence: 99%

“…A 24-h ambulatory ECG may be helpful in demonstrating ST-segment elevation [2,3,8,9]. According to Onaka et al [9], 22 of 30 patients (73%) with diagnosed variant angina demonstrated ST-segment elevation during monitoring. In the patient in whom the diagnosis of variant angina is elusive, for instance in the absence of ST-segment elevation that accompanies chest discomfort, various provocative tests (methylergonovine [10], acetylcholine [11], methacholine [12]) can be employed in an attempt to induce coronary artery spasm that can be visualized angiographically and is accompanied by ST-segment elevation [2,3].…”

Section: Discussionmentioning

confidence: 99%

Cardiac arrest related to coronary spasm in patients with variant angina: a three‐case study

Seniuk¹,

Mularek‐Kubzdela²,

Grygier³

et al. 2002

Journal of Internal Medicine

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We present three patients with variant angina pectoris and episodes of cardiac arrest. All of them had typical clinical symptoms, ST‐segment changes in electrocardiogram, and coronary artery spasm confirmed by arteriography. They were treated with high doses of calcium antagonists and nitrates. An automatic cardioverter‐defibrillator was implanted in the patient who developed ventricular fibrillation despite therapy with calcium antagonists. In another patient a DDD pacemaker was implanted because of high‐degree atrioventricular block.

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“…2,13 Previous studies have indicated that multivessel coronary spasm is an important predictor of survival in patients with variant angina 1-4 and the incidence of multivessel spasm has been reported to range from 25 to 76%. [5][6][7] If all patients with multivessel spasm were at high risk of sudden death, however, the prognosis should be worse, so there seems to be a low-risk subgroup among multivessel spasm patients.…”

Section: Discussionmentioning

confidence: 99%

Prognostic Significance of the Pattern of Multivessel Spasm in Patients With Variant Angina

et al. 1999

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Clinical observation of spontaneous anginal attacks and multivessel spasm in variant angina pectoris with normal coronary arteries: Evaluation by 24-hour 12-lead electrocardiography with computer analysis

Abstract: Although the prognosis of multivessel spasm is believed to be poor, this may not necessarily be so. Anginal attacks due to sequential and simultaneous multivessel spasm seem to be more dangerous than those involving single-vessel spasm or migratory multivessel spasm.

Cited by 59 publications

References 29 publications

Multifocal spasm with acetylcholine in Prinzmetal angina

Multifocal spasm with acetylcholine in Prinzmetal angina

Cardiac arrest related to coronary spasm in patients with variant angina: a three‐case study

Prognostic Significance of the Pattern of Multivessel Spasm in Patients With Variant Angina

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