Spasm Provocation Tests Performed under Medical Therapy: A New Approach for Treating Patients with Refractory Coronary Spastic Angina on Emergency Admission

Abstract

Objective There are no objective methods for evaluating the severity of vasospasms in patients with refractory coronary spastic angina (R-CSA) under adequate medical therapy. We examined whether spasm provocation tests performed under adequate medication are useful for evaluating the severity of disease in R-CSA patients on emergency admission. Methods and ResultsWe performed spasm provocation tests before and after the administration of medical therapy in eight R-CSA patients, including one ventricular fibrillation survivor (VF-S) and seven patients with unstable angina (UAP) on emergency readmission. We also performed these tests only after medical therapy on urgent admission in four R-CSA patients, including two patients with UAP, one patient with VF-S and one patient with acute coronary syndrome. All 12 R-CSA patients had been medicated with ! 2 vasodilator drugs. Positive coronary spasms were defined as >99% transient narrowing. The coronary artery spasms disappeared in three patients under medication, and mitigation of vasospasticity was observed in three patients. In these six cases we continued the same medications. Meanwhile in two patients, we recommended a consultation for psychosomatic medicine. In contrast, the remaining six R-CSA patients exhibited higher levels of vasospasticity, irrespective of the administration of aggressive medical therapy, in which the doses of vasoactive drugs were increased in order to suppress coronary artery spasms. Conclusion In some R-CSA patients on emergency admission, performing spasm provocation tests under medical therapy is useful for determining the subsequent treatment strategy. Therefore, this test may become a new tool in the treatment of R-CSA.

Optimal Medications and Appropriate Implantable Cardioverter-defibrillator Shocks in Aborted Sudden Cardiac Death Due to Coronary Spasm

“…Eschalier et al reported the clinical use of ergonovine tests under the optimal medications when cardiologists considered the necessity of ICD implantation in patients with aborted SCD due to coronary spasm ( 32 ). We also reported the results of pharmacological spasm provocation testing under patients with refractory spasm who were treated with medical therapy ( 44 ). ICD implantation may not be always necessary for patients with aborted SCD who had life-threatening ventricular arrhythmia and coronary spasm.…”

Cardiogenic Shock due to Pulseless Electrical Activity Arrest Associated with Severe Coronary Artery Spasm

“…When the ergonovine test was negative under the optimum treatment conditions, they recommend individual discussion for ICD implantation; if the test was positive, they recommend ICD implantation in all cases, even if the optimum treatment was being administered. We also reported the findings of sequential spasm provocation tests in these near-miss patients under the optimum treatment conditions ( 10 ). If a positive provoked is not noted on a sequential spasm provocation test under optimum medical therapy in patients with aborted sudden cardiac death due to coronary spasm, cardiologists and patients are free to select a course of medical treatment without ICD implantation.…”

Spasm Provocation Tests under Medication May Help Decide on Medical or Mechanical Therapy in Patients with Aborted Sudden Cardiac Death due to Coronary Spasm

“…The spasm provocation data are shown in Table 2, and the total doses of precise vasodilators, including calcium channel blockers, are shown in Table 3. We have already reported three cases (case 2, 3, and 4) (12,13).…”