Coronary vasospasm: A narrative review

Abstract

Coronary artery vasospasm (CAVS) plays an important role in acute chest pain syndrome caused by transient and partial or complete occlusion of the coronary arteries. Pathophysiology of the disease remains incompletely understood, with autonomic and endothelial dysfunction thought to play an important role. Due to the dynamic nature of the disease, its exact prevalence is not entirely clear but is found to be more prevalent in East Asian and female population. Cigarette smoking remains a prominent risk factor, although CAVS does not follow traditional coronary artery disease risk factors. Many triggers continue to be identified, with recent findings identifying chemotherapeutics, allergens, and inflammatory mediators as playing some role in the exacerbation of CAVS. Provocative testing with direct visualization is currently the gold-standard for diagnosis, but non-invasive tests, including the use of biomarkers, are being increasingly studied to aid in the diagnosis. Treatment of the CAVS is an area of active research. Apart from risk factor modification, calcium channel blockers are currently the first line treatment, with nitrates playing an important adjunct role. High-risk patients with life-threatening complications should be considered for implantable cardioverter defibrillator (ICD), although timing criteria for escalated therapy require further investigation. The role of pharmaceuticals targeting oxidative stress remains incompletely understood.

Slow-flow phenomenon after drug-coated balloon angioplasty for lower-extremity arteries is associated with lack of prescribing of calcium channel blockers

“…An association between smoking and endothelial injury has been reported, which may result in vasospasms. 8 , 9 …”

Coronary sinus spasm with catheter entrapment and adjacent coronary artery compression during an ablation procedure in a child

“…14 Additional factors implicated in the pathogenesis of J o u r n a l P r e -p r o o f coronary arterial vasospasm include endothelial dysfunction, oxidative stress, and autonomic and genetic elements. 15 Obstruction of adjacent coronary arterial flow was a major factor in our proactive approach to extracting the entrapped catheter as opposed to adopting a more conservative strategy of watchful waiting for the spasm to subside either spontaneously or after administration of a systemic vasodilator. The mechanism for severe obstruction of the adjacent circumflex coronary artery also remains speculative.…”

“…14 Additional factors implicated in the pathogenesis of coronary arterial vasospasm include endothelial dysfunction, oxidative stress, and autonomic and genetic elements. 15 …”

Invasive Evaluation for Coronary Vasospasm

“…β-blockers should be avoided in clear vasospastic syndromes, as alternative treatments with better evidence exist. 92 However, in patients with mixed VSA and CMD, most studies support the use of nebivolol for its vasodilatory effect, which may improve parameters of microvascular function without causing vasospasm. Further studies on nebivolol in VSA are needed.…”