Medline ® Abstracts for References 95,96
of 'Fluoropyrimidine-associated cardiotoxicity: Incidence, clinical manifestations, mechanisms, and management'
Provocative testing for coronary reactivity and spasm.
Zaya M, Mehta PK, Merz CN
J Am Coll Cardiol. 2014 Jan;63(2):103-9. Epub 2013 Nov 6.
Coronary spasm is an important and often overlooked etiology of chest pain. Although coronary spasm, or Prinzmetal's angina, has been thought of as benign, contemporary studies have shown serious associated adverse outcomes, including acute coronary syndrome, arrhythmia, and death. Definitive diagnosis of coronary spasm can at times be difficult, given the transience of symptoms. Numerous agents have been historically described for provocative testing. We provide a review of published data for the role of provocation testing in the diagnosis of coronary spasm.
Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California.
Clinical usefulness, angiographic characteristics, and safety evaluation of intracoronary acetylcholine provocation testing among 921 consecutive white patients with unobstructed coronary arteries.
Ong P, Athanasiadis A, Borgulya G, Vokshi I, Bastiaenen R, Kubik S, Hill S, Schäufele T, Mahrholdt H, Kaski JC, Sechtem U
Circulation. 2014;129(17):1723. Epub 2014 Feb 26.
BACKGROUND: Coronary spasm can cause myocardial ischemia and angina in patients with and those without obstructive coronary artery disease. However, provocation tests using intracoronary acetylcholine administration are rarely performed in clinical routine in the United States and Europe. Thus, we assessed the clinical usefulness, angiographic characteristics, and safety of intracoronary acetylcholine provocation testing in white patients with unobstructed coronary arteries.
METHODS AND RESULTS: From September 2007 to June 2010, a total of 921 consecutive patients (362 men, mean age 62±12years) who underwent diagnostic angiography for suspected myocardial ischemia and were found to have unobstructed coronary arteries (no stenosis≥50%) were enrolled. The intracoronary acetylcholine provocation testing was performed directly after angiography according to a standardized protocol. Three hundred forty-six patients (35%) reported chest pain at rest, 222 (22%) reported chest pain on exertion, 238 (24%) reported a combination of effort and resting chest pain, and 41 (4%) presented with troponin-positive acute coronary syndrome. The overall frequency of epicardial spasm (>75% diameter reduction with angina and ischemic ECG shifts) was 33.4%, and the overall frequency of microvascular spasm (angina and ischemic ECG shifts without epicardial spasm) was 24.2%. Epicardial spasm was most often diffuse and located in the distal coronary segments (P<0.01). No fatal or irreversible nonfatal complications occurred. However, 9 patients (1%) had minor complications (nonsustained ventricular tachycardia [n=1], fast paroxysmal atrial fibrillation [n=1], symptomatic bradycardia [n=6], and catheter-induced spasm [n=1]).
CONCLUSIONS: Epicardial and microvascular spasm are frequently found in white patients with unobstructed coronary arteries. Epicardial spasm is most often diffuse and located in the distal coronary segments. The intracoronary acetylcholine provocation test is a safe technique to assess coronary vasomotor function.
Robert-Bosch-Krankenhaus, Department of Cardiology, Stuttgart, Germany (P.O., A.A., S.H. T.S., H.M., U.S.); St George's University of London, Clinical Trials Unit, London, United Kingdom (G.B.); and Cardiovascular Sciences Research Centre, St George's University of London, London, United Kingdom (I.V., R.B., S.K., J.C.K.).