Walk-through angina phenomenon demonstrated by graded exercise radionuclide ventriculography: Possible coronary spasm mechanisms

Rizi, H. Roger; Kline, Robert C.; Besozzi, Myrwood C.; Kalf, Victor; Rabinovitch, Mark A.; Chan, William; Trall, James H.; Pitt, Bertram

doi:10.1016/0002-8703(82)90504-x

Cited by 21 publications

(10 citation statements)

References 5 publications

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“…Subjects were selected from a group of patients undergoing diagnostic cardiac catheterization and with a history of stable exertional angina pectoris. The following inclusion criteria had to be met: ( 1) coronary angiographic documentation of 70% or greater (diameter reduction) stenosis of the proximal left anterior descending coronary artery, (2) absence of 50% or greater stenosis of the left main, circumflex, or right coronary artery, (3) no nitrate administration during the diagnostic phase of cardiac catheterization, (4) ability to catheterize the great cardiac vein of the patient with a thermodilution catheter, (5) presence of sinus rhythm, and (6) willingness of the patient to participate in the investigation. Eleven patients were recruited.…”

Section: Methodsmentioning

confidence: 99%

“…They further emphasized the interrelationship between the two entities by suggesting that the warm-up phenomenon may be a forme fruste of walk-through angina since they observed patients in whom the former evolved into the latter. These investigators and others3 4 have suggested that a decrease in myocardial oxygen consumption is not the underlying mechanism responsible for increased tolerance to exercise. Rather, they postulate that enhanced coronary blood flow during the second exercise period is the responsible mechanism.…”

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confidence: 89%

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Adaptation to the stress of tachycardia in patients with coronary artery disease: insight into the mechanism of the warm-up phenomenon.

Williams¹,

Bass²,

Gewirtz³

et al. 1985

Circulation

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Adaptation to exercise or the "warm up phenomenon" has been observed in some patients with angina pectoris. To investigate adaptation, eleven patients with exertional angina pectoris and angiographic evidence of coronary artery disease underwent two identical bouts of sequential tachycardia stress separated by a brief recovery period. Manifestations of ischemia were less during the second stress, as evidenced by a reduction in the severity of angina pectoris, less ST segment depression, and improved lactate extraction. Peak coronary blood flow during the second stress (81 + 20 ml/min) was not significantly different from that during the first (95 + 32 ml/min). Regional myocardial oxygen consumption, however, was significantly (p = .03) lower during the second stress (8.8 2.4 ml 02/min) when compared with the first (1 1.4 + 3.0 ml 02/min). Thus, patients with coronary artery disease can develop anginal tolerance to the stress of tachycardia similar to that observed after repeated bouts of exercise. A relative reduction in myocardial oxygen consumption, rather than an increase in coronary blood flow, appears to account for this phenomenon. Circulation 71, No. 4, 687492, 1985. IN 1785, William Heberdeen described a patient in whom angina pectoris initially developed during exercise but then paradoxically disappeared as exercise was continued.' This phenomenon has been termed "walk through" or "second wind" angina. A related form of angina has also been acknowledged wherein a patient, after terminating exercise because of the development of angina, is subsequently able to resume angina-free exercise. This latter adaptation has been termed the "warm up phenomenon" or "angina of first effort."Several investigators have documented reduced myocardial ischemia in patients demonstrating either walk-through angina or the warm-up phenomenon during exercise stress testing. MacAlpin and Kattus2 described 12 patients who were able to adapt to treadmill exercise. Nine patients demonstrated the disappearance or lessening of anginal pain and ischemic ST segment depression with continued walking. Three patients showed increased exercise capacity after having been "warmed up" by a prior exercise period that re-

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Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 89%

Adaptation to the stress of tachycardia in patients with coronary artery disease: insight into the mechanism of the warm-up phenomenon.

Williams¹,

Bass²,

Gewirtz³

et al. 1985

Circulation

View full text Add to dashboard Cite

show abstract

“…The relative rarity of the WTP during exer cise testing, as shown by the occurrence of this condition in only 3 cases out of 3,900 patients of our series, is thought to be second ary to the protocol generally used in the exer cise laboratories where the patients are sub jected to graded increase in workload, while the phenomenon is commonly observed Pressure-rate product. this patient always induced mild chest pain at low workloads, while at higher workloads angina disap when the workload is relatively constant [8]. Indeed, the largest number of observations were reported in 1966 by McAlpin and Kattus [6] who exercised their patients on a motordriven treadmill with increasing speeds to the onset of chest pain when the speed was held constant until the patients could walk through their angina.…”

Section: Discussionmentioning

confidence: 97%

“…These authors postulated that in the former group of patients collateral channels may respond slowly to the dilating stimulus of myocardial ischemia, while in the latter group it may be the major vessels which maintain a capability of dilation at their ste notic points. Recent observations have sug gested that coronary spasm may play a role in the pathogenesis of the WTP [8,9]. Sturzenhofecker et al [9] presented one patient com plaining of spontaneous as well as effort angi na.…”

Section: Discussionmentioning

confidence: 99%

Significance of the Walk-Through Angina Phenomenon during Exercise Testing

Gavazzi¹,

Servi²,

Cornalba³

et al. 1986

Cardiology

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Out of 3,900 patients who performed an exercise test at our clinic, 3 patients demonstrated a walk-through phenomenon (WTP), defined as the occurrence of mild angina during the first stages of exercise with disappearance of chest pain at higher workloads despite a greater pressure-rate product. 2 patients had variant angina, one with normal coronary arteries and the other with single vessel disease, while the third patient had stable exertional angina and a severe coronary artery disease with occlusion of two major vessels retrogradely filled by collateral channels. Repeat exercise tests failed to reproduce constantly the WTP in the 2 patients with variant angina, while in the third patient the phenomenon was repeatedly induced by exercise testing. Thus the WTP, although rarely found during exercise testing, can be observed in two subsets of patients. In variant angina the WTP is not reproducible and is probably due to coronary spasm, spontaneously subsiding during exercise. In patients with exertional angina and severe coronary artery disease, the WTP can be repeatedly observed during exercise and is likely to be secondary to a delayed vasodilation of collateral vessels. The clinical characteristics of the patients and the response to repeat exercise tests may be useful in identifying the different pathogenetic mechanisms.

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“…The walk-through phenomenon is explained by a gradual increase in blood supply to the jeopardized myocardium in the presence of unchanged or increased myocardial oxygen requirement [1][2][3]. This is accomplished by two different mechanisms.…”

Section: Introductionmentioning

confidence: 99%

Improvement of ST Segment Depression by Gradual Recruitment of Collateral Circulation

Tanaka

Fujita²,

Hirai³

et al. 1990

Cardiology

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The purpose of the present study was to document that the coronary collateral vessels do not open immediately upon the occurrence of myocardial ischemia. A multistage bicycle exercise was performed to determine a maximal tolerable work load until the onset of angina and significant ST segment depression in 10 patients with well-developed collateral circulation. On a different day, exercise with the maximal tolerable work load was repeated for a comparable exercise duration. In 2 of the 10 patients, anginal pain was gradually alleviated despite the continuation of exercise with fixed work load. The extent of ST segment depression at 3 min of exercise with fixed work load was 0.20 ± 0.10 (SD) mV, significantly (p < 0.05) greater than 0.16 ± 0.08 mV at the end of exercise with fixed work load. In contrast, the rate-pressure product was smaller at 3 min than at the end of exercise with fixed work load (20,900 ± 5,500 vs. 22,700 ± 5,700 mm Hg · beats/min; p < 0.05). In 5 patients without well-developed collateral circulation, the extent of ST depression changed in parallel with changes in rate-pressure product during exercise with fixed work load. Thus, it is concluded that the delayed collateral opening plays a critical role in the pathogenesis of myocardial ischemia in patients with a totally occluded coronary artery.

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Walk-through angina phenomenon demonstrated by graded exercise radionuclide ventriculography: Possible coronary spasm mechanisms

Cited by 21 publications

References 5 publications

Adaptation to the stress of tachycardia in patients with coronary artery disease: insight into the mechanism of the warm-up phenomenon.

Adaptation to the stress of tachycardia in patients with coronary artery disease: insight into the mechanism of the warm-up phenomenon.

Significance of the Walk-Through Angina Phenomenon during Exercise Testing

Improvement of ST Segment Depression by Gradual Recruitment of Collateral Circulation

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