The Need for Separate Testing with Acetylcholine for the Assessment of Endothelial Dysfunction and Coronary Artery Spasm.

Intracoronary acetylcholine (ACH) testing is clinically useful to diagnose the presence of the coronary vasomotor disorders coronary endothelial dysfunction and coronary epicardial/microvascular spasm. In Western countries, continuous intracoronary injection of ACH for 2-3 minutes without a pacemaker is the usual method, while rapid injection of ACH for 20-30 seconds with a pacemaker is the traditional procedure in Japan. Coronary microvascular spasm is often observed in Western populations, whereas coronary epicardial spasm is frequently seen in Japanese subjects.

A Review of the Role of Tests of Coronary Reactivity in Clinical Practice.

Vasoreactivity testing is used by cardiologists in the diagnosis of coronary spasm endotypes, such as epicardial and microvascular spasm. Intracoronary injection of acetylcholine and ergonovine is defined as a standard class I method according to the Coronary Vasomotion Disorder (COVADIS) Group. Because single vasoreactivity testing may have some clinical limitations in detecting the presence of coronary spasm, supplementary or sequential vasoreactivity testing should be reconsidered.

Pharmacological spasm provocation testing in 2500 patients: provoked spasm incidence, complications and cardiac events.

Pharmacological spasm provocation tests such as acetylcholine (ACh) and ergonovine (ER) had been performed in the clinic. We retrospectively analyzed the incidence of provoked spasm, complications during testing and the cardiac events after these tests. From January 1991 and October 2018, we performed pharmacological spasm provocation tests in 2500 patients: 1810 ACh tests, 1232 ER tests, 542 both tests, and 310 ACh added after ER tests.

General internists of experience suspected variant angina as gastroesophageal reflux diseases in two cases: Heart burn may be related to coronary spasm.

General physicians of experience suspected variant angina as gastroesophageal reflux disease (GERD) due to heart burn in two patients. Proton pump inhibitors were administered in these patients, although spontaneous ST segment elevations were recognized and total or subtotal coronary spasm was provoked by the pharmacological spasm provocation tests. Under the vasodilators but not proton pump inhibitors, two patients complained of neither heart burn nor chest symptoms.

Ventricular fibrillation survivor due to painless multiple spasm including left main trunk: is the subcutaneous implantable cardioverter-defibrillator necessary?

A 52-year-old man was transferred to our hospital for ventricular fibrillation. He had no chest symptoms until then. After his full recovery, the administration of acetylcholine 20 μg showed the multiple spasm (left main trunk/left anterior descending artery/right coronary artery) without any chest symptoms or ischemic electrocardiographic changes.

Spontaneous coronary artery spasm detected by computed tomography coronary angiography: Provoked spasm site similar to intracoronary injection of ergonovine but not acetylcholine.

A 61-year-old man was admitted to our hospital due to chest pain on both rest and effort. After the computed tomography coronary angiography, coronary stenosis was recognized at segment 3. Because inferior ischemia on stress myocardial perfusion scintigraphy with 201 thallium chloride induced by adenosine was found, we planned to perform the coronary intervention.

Young Vasospastic Angina Patients Less Than 20 Years Old.

Background: Japanese Circulation Society (JCS) guidelines do not include adolescents with coronary artery spasm.

Methods and results: We recruited 18 adolescents less than 20 years old with vasospastic angina (VSA): 11 were Japanese and 3 had chest symptoms for >12 months before admission. ST-segment elevation was observed in 11 patients and none of the 18 patients had a fixed stenosis.

Dose maximal acetylcholine dose into the left coronary artery affect the positive provoked spasm in the left circumflex artery?

Background: Positive provoked spasm in the left circumflex artery (LCX) is lower than that in the left anterior descending artery and right coronary artery (RCA).

Patients And Methods: We examined the provoked positive spasm in the LCX between the maximal acetylcholine (ACh) 100 μg period (January 1991 to July 2012, 1474 patients: the former period) and the maximal ACh 200 μg period (August 2012 to August 2018, 336 patients: the latter period). ACh was injected in incremental dose of 20/50/100/200 μg into the left coronary artery and of 20/50/80 μg into the RCA.

Acetylcholine spasm provocation test by trans-radial artery and brachial vein approach.

Background: Temporary pace maker is necessary because of transient block or bradycardia during the intracoronary acetylcholine spasm provocation tests based on the Japanese Circulation Society guidelines.

Objectives: We examined the feasibility and safety of the acetylcholine spasm provocation test via the radial artery and brachial vein approach.

Methods: We tried to perform the acetylcholine spasm provocation tests in 252 patients via the radial artery and brachial vein approach procedures during 5 years.

Differential incidence and morphology of provoked spasm between intracoronary acetylcholine and ergonovine testing: recommendation of supplementary use.

When cardiologists diagnose patients with coronary spastic angina, Japanese Circulation Society (JCS) guidelines recommend the intracoronary injection of acetylcholine (ACh) and ergonovine (ER) as class I. However, the pharmacological difference between ACh and ER is controversial in the clinic. We performed both ACh and ER tests in the same 528 patients during 26 years.

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

A 75-year-old man was admitted to our hospital for follow-up coronary angiography. Just after starting coronary angiography, his electrocardiogram showed ST-segment elevation in the V1-6, I, II, and aVF leads, and he fell into catastrophic cardiogenic shock. His left coronary arteriogram showed proximal total obstruction in the left anterior descending artery and proximal subtotal occlusion in the left circumflex artery.

Differential Incidence and Morphology of Spasm According to Coronary Arterial Location by Intracoronary Ergonovine Spasm Provocation Testing.

Background: We reported less provoked spasm in the left circumflex artery (LCX) by acetylcholine testing compared with the left anterior descending artery (LAD) and right coronary artery (RCA), so we investigated the clinical characteristics of provoked spasm in the LCX by ergonovine (ER) testing.

Methods and results: We retrospectively analyzed 1,185 consecutive cases of intracoronary ER testing during 25 years. Maximal ER dose was 64 μg into the left coronary artery (LCA) and 40 μg into the RCA.

The acetylcholine administration time plays the key role for provoked spasm in the spasm provocation test.

Background: Acetylcholine (ACh) was administered for 3min in the ENCORE study, while the Japanese Circulation Society guidelines recommended the 20s ACh injection as an ACh test.

Objectives: We compared the ischemic findings between ACh administration for 3min and ACh injection for 20s in the same patients and in the same ACh doses without administration of nitrates in the left coronary artery.

Methods: We investigated 30 patients with ischemic heart disease (25 men, 67±10 years, ACh 50μg: 3, ACh 100μg: 9, ACh 200μg: 18) by the above two ACh injection procedures.

Differential incidence and type of spasm according to coronary arterial location.

Background: We encounter a less provoked spasm in the left circumflex artery (LCX) by acetylcholine (ACh) testing compared with left anterior descending artery and right coronary artery (RCA) in the real world.

Objectives: We investigated the clinical characteristics of provoked spasm in the LCX by ACh testing.

Methods: We retrospectively analyzed consecutive 1392 ACh testing over 20 years (1991-2011).

Overview of the Acetylcholine Spasm Provocation Test.

The acetylcholine (ACh) spasm provocation test proposed by Yasue, Okumura et al more than a quarter-century ago has become a popular method for induction of coronary spasm. This test is safe and has a low rate of complications. However, it may be limited in its ability to document attacks in daily life because previously it was the gold-standard method for diagnosing active variant angina.

Silent coronary spastic angina: A report of a case.

A 54-year-old man was admitted to our hospital due to abnormal electrocardiogram (ECG) changes. He had experienced no chest pain or chest discomfort during daily life until then. Ischemic ECG change was obtained by the treadmill exercise test but he complained of no chest pain or chest oppression.

One of six patients with non-ischemic heart disease exhibit provoked coronary spasms: non-ischemic heart disease associated with ischemia?

Objective: The majority of cardiologists do not perform spasm provocation tests in patients with non-ischemic heart disease (non-IHD) or non-obstructive coronary artery disease (non-ob-CAD). We herein examined the frequency of provoked spasms in non-IHD and non-ob-CAD patients, including those with atypical chest pain (Aty), valvular heart disease (Val), hypertrophic cardiomyopathy (HCM), congestive heart failure (CHF), and others (Oth).

Methods & Results: We performed acetylcholine (ACh) spasm provocation tests over a period of 22 years (1991-2012) among 1,440 patients, including 981 IHD and 459 non-IHD subjects.

Complete definite positive spasm on acetylcholine spasm provocation tests: comparison of clinical positive spasm.

In the clinical grounds, patients with ≥90 % luminal narrowing during acetylcholine (ACh) testing had variable response. We investigated ischemic findings and chest symptoms in patients with ≥90 % luminal narrowing when performing ACh tests, retrospectively. We performed 763 ACh tests over 13 years (2001-2013).

Safety and optimal protocol of provocation test for diagnosis of multivessel coronary spasm.

We examined the safety of acetylcholine (ACh) and ergonovine (ER) tests retrospectively and investigated the optimal protocol of provocation test for diagnosis of multivessel coronary spasm. We performed 1546 ACh tests and 1114 ER tests during 23 years. ACh was injected in incremental doses of 20/50/80 μg into the right coronary artery (RCA) and of 20/50/100/200 μg into the left coronary artery (LCA) over 20 s.

Maximal acetylcholine dose of 200 μg into the left coronary artery as a spasm provocation test: comparison with 100 μg of acetylcholine.

As a spasm provocation test of acetylcholine (ACH), incremental dose up (20/50/100 μg) into the left coronary artery (LCA) is recommended in the guidelines established by Japanese Circulation Society. Recently, Ong et al. reported the ACOVA study which maximal ACH dose was 200 μg in the LCA.

Spasm provocation tests performed under medical therapy: a new approach for treating patients with refractory coronary spastic angina on emergency admission.

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 Results We 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.