Ergonovine testing for coronary artery spasm in patients with angiographic mitral valve prolapse

Abstract

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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“…We also used intracoronary ergonovine in an attempt to minimize its systemic vascular effects which elevated myocardial oxygen demands and confounded the actual cause of ischemia among patients with co‐existing obstructive CAD. Ergonovine was assessed in patients with mitral valve prolapse 9 . We also studied the coronary artery responses to inhalation of cold air in the angiographic lab 10 …”

“…Ergonovine was assessed in patients with mitral valve prolapse. 9 We also studied the coronary artery responses to inhalation of cold air in the angiographic lab. 10 We intensely investigated coronary angiographic responses to various medications.…”

“…Ergonovine was assessed in patients with mitral valve prolapse. 9 We also studied the coronary artery responses to inhalation of cold air in the angiographic lab. 10 …”

Mitral Valve Prolapse and Spasm of Normal Coronary Arteries: Report of Four Cases and Review of the Literature

“…and coronary spasm. [15][16][17][18][19] Several lines of evidence point to underlying ischemia causing chest pain in MVP patients including electrocardiographic abnormalities, 1-5 arrhythmias '20-2:1 increased myocardial lactate production in MVP patients during ventricular pacing, 21 myocardial infarction 1;),2;) and sudden death. 26 Early speculation that coronary spasm caused chest pain in patients with MVP was based on circumstantial evidence such as documented myocardial infarction in a small number of patients with MVP and angiographically normal coronary arteries and occasional reports of ST segment elevation in MVP patients during pain.ls While several series showed angiographic evidence of coronary spasm in a few patients with MVP, 14,17,HJ the spasm often occurred around the catheter tip.17 Ergonovine testing in MVP patients with atypical chest pain has been largely unrewarding.…”