OBJECTIVE: To investigate the diagnostic validity of coronary computed tomography angiography (cCTA) in vasospastic angina (VA) and factors associated with discrepant results between invasive coronary angiography with the ergonovine provocation test (iCAG-EPT) and cCTA. MATERIALS AND METHODS: Of the 1397 patients diagnosed with VA from 2006 to 2016, 33 patients (75 lesions) with available cCTA data from within 6 months before iCAG-EPT were included. The severity of spasm (% diameter stenosis [%DS]) on iCAG-EPT and cCTA was assessed, and the difference in %DS (Δ%DS) was calculated. Δ%DS was compared after classifying the lesions according to pre-cCTA-administered sublingual nitroglycerin (SL-NG) or beta-blockers. The lesions were further categorized with %DS ≥ 50% on iCAG-EPT or cCTA defined as a significant spasm, and the diagnostic performance of cCTA on identifying significant spasm relative to iCAG-EPT was assessed. RESULTS: Compared to lesions without SL-NG treatment, those with SL-NG treatment showed a higher Δ%DS (39.2% vs. 22.1%, p = 0.002). However, there was no difference in Δ%DS with or without beta-blocker treatment (35.1% vs. 32.6%, p = 0.643). The significant difference in Δ%DS associated with SL-NG was more prominent in patients who were aged < 60 years, were male, had body mass index < 25 kg/m2, and had no history of hypertension, diabetes, or dyslipidemia. Based on iCAG-EPT as the reference, the per-lesion-based sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cCTA for VA diagnosis were 7.5%, 94.0%, 60.0%, 47.1%, and 48.0%, respectively. CONCLUSION: For patients with clinically suspected VA, confirmation with iCAG-EPT needs to be considered without completely excluding the diagnosis of VA simply based on cCTA results, although further prospective studies are required for confirmation.
Angina Pectoris, Variant ; Angiography ; Body Mass Index ; Constriction, Pathologic ; Coronary Angiography ; Diagnosis ; Dyslipidemias ; Ergonovine ; Humans ; Hypertension ; Male ; Nitroglycerin ; Prospective Studies ; Sensitivity and Specificity ; Spasm

Variant angina pectoris (VAP) is a special type of unstable angina with coronary artery spasm as the main pathogenesis, characterized by resting chest pain, and transient ST segment dynamic changes. The development of acute myocardial infarction is not uncommon. We report a case of a 49-year-old female patient diagnosed with VAP at 2 years before who suddenly suffered severe chest pain. Troponin-I was elevated. Immediate coronary angiography showed near-total occlusion in the proximal left anterior descending artery, which was not fully dilated despite use of intracoronary nitroglycerin. Intravascular ultrasound showed focal significant stenosis with a large amount of plaque at the site of spasm and the lesion was successfully treated with drug-eluting stent placement. Intravascular imaging may be instrumental in high-risk patients with VAP who suffer recurrent chest pain despite intensive anti-spasm medications.
Angina Pectoris, Variant ; Angina, Unstable ; Arteries ; Atherosclerosis* ; Chest Pain ; Constriction, Pathologic ; Coronary Angiography ; Coronary Vessels ; Drug-Eluting Stents ; Female ; Humans ; Middle Aged ; Myocardial Infarction* ; Nitroglycerin ; Spasm* ; Troponin I ; Ultrasonics ; Ultrasonography

We report the case of a middle aged woman who was previously diagnosed with hypertension. She had been drinking a kelp concentrate solution daily for her hypertension instead of taking the prescribed medicine due to her personal beliefs about the kelp solution. As a consequence, she experienced vasospastic angina complicated by myocardial infarction and cardiogenic syncope resulting from iatrogenic thyrotoxicosis. Complementary medicine is widely used by the general population. However, there is still a lack of evidence regarding their efficacy and safety. This case shows that inadequate use of complementary medicine could have no effect and may even be harmful. In patients with chronic diseases such as hypertension, self-care in the form of life style modification, home blood pressure monitoring and medial adherence are important for disease management.
Angina Pectoris, Variant ; Arteries* ; Blood Pressure Monitoring, Ambulatory ; Chronic Disease ; Complementary Therapies ; Disease Management ; Drinking ; Female ; Humans ; Hypertension ; Kelp ; Life Style ; Middle Aged ; Myocardial Infarction ; Self Care ; Syncope ; Thyrotoxicosis*

Prinzmetal's variant angina describes chest pain secondary to reversible coronary artery vasospasm in the context of both diseased and non-diseased coronary arteries. Symptoms typically occur when the patient is at rest and are associated with transient ST-segment elevation. Acute episodes respond to glyceryl trinitrate, but myocardial infarction and other potentially fatal complications can occur, and long-term management can be challenging. Although it is not well understood, the underlying mechanism appears to involve a combination of endothelial damage and vasoactive mediators. In this case, a 35-year-old woman with myocardial infarction secondary to coronary artery vasospasm experienced recurrent chest pain. Coronary angiography revealed severe focal stenosis in the mid left anterior descending artery, which completely resolved after administration of intracoronary glyceryl trinitrate. The patient was discharged on nitrates and calcium channel blockers. The patient re-presented with another myocardial infarction, requiring up-titration of medical therapy.
Adult ; Angina Pectoris, Variant ; complications ; drug therapy ; Constriction, Pathologic ; drug therapy ; pathology ; Coronary Angiography ; Coronary Vasospasm ; Coronary Vessels ; physiopathology ; Electrocardiography ; Female ; Humans ; Myocardial Infarction ; complications ; drug therapy ; pathology ; Nitroglycerin ; therapeutic use ; Recurrence ; Vasodilator Agents ; therapeutic use

Administration, Intravenous ; Angina Pectoris, Variant ; drug therapy ; Humans ; Male ; Middle Aged ; Solanaceous Alkaloids ; administration & dosage ; therapeutic use

Angina Pectoris, Variant ; metabolism ; physiopathology ; Coronary Vasospasm ; metabolism ; Dyslipidemias ; metabolism ; physiopathology ; Humans

Variant angina pectoris is characterized by chest symptoms at rest and transient ST elevation on the electrocardiography due to coronary artery spasm. Although most patients with coronary spasm respond well to medical treatment with vasodilators such as calcium channel blockers and nitrates, some patients show intractable attack of coronary vasospasm despite standard medical therapy. We experienced 50-year-old woman with intractable chest pain due to coronary artery spasm, who suffered from ventricular fibrillation despite continuous intravenous nitrate therapy.
Angina Pectoris, Variant ; Arrhythmias, Cardiac* ; Calcium Channel Blockers ; Chest Pain ; Coronary Vasospasm ; Coronary Vessels ; Electrocardiography ; Female ; Humans ; Middle Aged ; Muscle Spasticity* ; Nitrates ; Nitroglycerin* ; Spasm ; Thorax ; Vasodilator Agents ; Ventricular Fibrillation

BACKGROUND/AIMS: The incidence of variant angina (VA) is relatively high in Korea compared with western countries, but its long-term clinical outcomes are not well defined. METHODS: Patients who underwent ergonovine provocation tests at the cardiac catheterization laboratory of Chonnam National University Hospital between 1996 and 2011 were enrolled in this study (n = 1162). Of them, 686 patients with positive ergonovine provocation tests were divided into two groups: patients with cardiac events (Group I: 153 patients, 52.4 +/- 11.0 years, M: F = 103: 50) and those without (Group II: 533 patients, 51.6 +/- 10.7 years, M: F = 350: 183). The mean follow-up duration was 40.2 +/- 38.0 months. Cardiac events were defined as cardiac death, recurrent ischemia, rehospitalization, myocardial infarction, and follow-up angiography. Clinical findings, laboratory and coronary angiographic characteristics were compared between the groups. RESULTS: A history of smoking was more common in Group I than in Group II (45.8% vs. 36.3%, p = 0.037). The levels of low-density lipoprotein cholesterol (119.4 +/- 35.3 vs. 111.1 +/- 32.2 mg/dL, p = 0.010) were higher in Group I than in Group II. According to Cox proportional hazard regression analysis, the major predictive factor for cardiac events during clinical follow-up was smoking (HR 1.80, 95% CI 1.036-3.126, p = 0.037). CONCLUSIONS: A history of smoking was the only independent risk factor for cardiac events during a long-term clinical follow-up in Korean patients with variant angina.
Angina Pectoris, Variant ; Angiography ; Cardiac Catheterization ; Cardiac Catheters ; Cholesterol ; Coronary Artery Disease ; Death ; Ergonovine ; Follow-Up Studies ; Humans ; Incidence ; Ischemia ; Korea ; Lipoproteins ; Myocardial Infarction ; Risk Factors ; Smoke ; Smoking

BACKGROUND AND OBJECTIVES: The intracoronary injection of acetylcholine (Ach) has been shown to induce coronary spasms in patients with variant angina. Clinical significance and angiographic characteristics of patients with a significant response to lower Ach dosages are as-yet non-clarified compared with patients responding to higher Ach doses. SUBJECTS AND METHODS: A total of 3034 consecutive patients underwent coronary angiography with Ach provocation tests from January 2004 to August 2010. Ach was injected in incremental doses of 20, 50, 100 microg into the left coronary artery. Significant coronary artery spasm was defined as focal or diffuse severe transient luminal narrowing (>70%) with/without chest pain or ST-T change on the electrocardiogram (ECG). We compared the clinical and angiographic characteristics of patients who responded to a lower Ach dose (20 or 50 microg, n=556) to those that responded to a higher Ach dose (100 microg, n=860). RESULTS: The baseline clinical and procedural characteristics are well balanced between the two groups, except diabetes was higher in the lower Ach dose group and there were differences in medication history. After adjusting for confounding factors, the lower Ach dose group showed more frequent temporary ST elevation and atrioventricular block on the ECG. Furthermore, the group of patients who responded to the lower Ach dose was associated with a higher incidence of baseline and severe spasm than those who responded to a higher Ach dose. CONCLUSION: Patients with a significant response to a lower Ach dose were associated with more frequent ST elevation, baseline spasm, and more severe spasm compared with those who responded to a higher Ach dose, suggesting more intensive medical therapy with close clinical follow-up is required for those patients.
Acetylcholine ; Angina Pectoris, Variant ; Atrioventricular Block ; Chest Pain ; Coronary Angiography ; Coronary Vessels ; Electrocardiography ; Humans ; Incidence ; Phenobarbital ; Spasm

Ergonovine provocation test is known to be very sensitive for diagnosing variant angina. The patient described in this study initially presented with atypical chest pain and underwent coronary angiography and ergonovine provocation tests, which were negative. The patient was subsequently prescribed a proton pump inhibitor and prokinetics for pain relief, but then presented with acute myocardial infarction and cardiogenic shock due to coronary artery vasospasm 5 years later. This case suggests that ergonovine provocation test generates false negative results, which can lead to unwanted outcomes. Even with a negative ergonovine provocation test, prescription of calcium channel blockers or nitrates should be considered in patients with a clinical history suggestive of variant angina.
Angina Pectoris, Variant ; Calcium Channel Blockers ; Chest Pain ; Coronary Angiography ; Coronary Vasospasm ; Ergonovine ; Humans ; Myocardial Infarction ; Nitrates ; Prescriptions ; Proton Pump Inhibitors ; Shock, Cardiogenic