scholarly journals Does Coronary Microvascular Spasm Exist? Objective Evidence from Intracoronary Doppler Flow Measurements During Acetylcholine Testing

2020 ◽  
Vol 4 (3) ◽  
pp. 205-209
Author(s):  
Fabian Guenther ◽  
Andreas Seitz ◽  
Valeria Martínez Pereyra ◽  
Raffi Bekeredjian ◽  
Udo Sechtem ◽  
...  
Keyword(s):  
Coronary Flow ◽  
Coronary Spasm ◽  
Coronary Microvascular Dysfunction ◽  
Flow Measurements ◽  
Doppler Flow ◽  
Intracoronary Doppler ◽  
Intracoronary Administration ◽  
Objective Evidence ◽  
Microvascular Spasm ◽  
Provocation Testing

A 43-year-old woman with recurrent atypical angina underwent invasive coronary angiography including intracoronary Doppler blood flow assessment and coronary spasm provocation testing. While obstructive epicardial disease could be ruled-out angiographically, the patient experienced reproduction of her angina symptoms after intracoronary administration of acetylcholine (100 µg) during spasm provocation testing. Simultaneously, the ECG showed new-onset ST-segment depression in the absence of epicardial spasm. In addition, coronary flow velocity was significantly reduced after acetylcholine compared to the baseline condition. Following intracoronary administration of nitroglycerine (200 µg), the patient’s symptoms as well as the ECG changes and coronary flow reduction were reversed. Considering the ongoing challenges in appropriate evaluation of the pathophysiological mechanisms of coronary microvascular dysfunction, simultaneous intracoronary Doppler flow measurement during spasm testing ‐ as shown in this case ‐ may provide objective evidence for microvascular spasm in addition to the standardized diagnostic criteria, especially if they are ambiguous.

Computer Analysis of Coronary Doppler Flow Velocity

2008 ◽  
pp. 281-289
Author(s):  
Valentina Magagnin ◽  
Maurizio Turiel ◽  
Sergio Cerutti ◽  
Luigi Delfino ◽  
Enrico Caiani
Keyword(s):  
Blood Flow ◽  
Coronary Artery ◽  
Flow Velocity ◽  
Coronary Blood Flow ◽  
Doppler Echocardiography ◽  
Coronary Flow ◽  
Connective Tissue Diseases ◽  
Doppler Flow ◽  
Intracoronary Doppler ◽  
Artery Disease

The coronary flow reserve (CFR) represents an important functional parameter to assess epicardial coronary stenosis and to evaluate the integrity of coronary microcirculation (Kern, 2000; Sadamatsu, Tashiro, Maehira, & Yamamoto, 2000). CFR can be measured, during adenosine or dipyridamole infusion, as the ratio of maximal (pharmacologically stimulated) to baseline (resting) diastolic coronary blood flow peak. Even in absence of stenosis in epicardial coronary artery, the CFR may be decreased when coronary microvascular circulation is compromised by arterial hypertension with or without left ventricular hypertrophy, diabetes mellitus, hypercholesterolemia, syndrome X, hypertrophic cardiomyopathy, and connective tissue diseases (Dimitrow, 2003; Strauer, Motz, Vogt, & Schwartzkopff, 1997). Several methods have been established for measuring CFR: invasive (intracoronary Doppler flow wire) (Caiati, Montaldo, Zedda, Bina, & Iliceto, 1999b; Lethen, Tries, Brechtken, Kersting, & Lambertz, 2003a; Lethen, Tries, Kersting, & Lambertz, 2003b), semi-invasive and scarcely feasible (transesophageal Doppler echocardiography) (Hirabayashi, Morita, Mizushige, Yamada, Ohmori, & Tanimoto, 1991; Iliceto, Marangelli, Memmola, & Rizzon, 1991; Lethen, Tries, Michel, & Lambertz, 2002; Redberg, Sobol, Chou, Malloy, Kumar, & Botvinick, 1995), or extremely expensive and scarcely available methods (PET, SPECT, MRI) (Caiati, Cioglia, Montaldo, Zedda, Rubini, & Pirisi, 1999a; Daimon, Watanabe, Yamagishi, Muro, Akioka, & Hirata, 2001; Koskenvuo, Saraste, Niemi, Knuuti, Sakuma, & Toikka, 2003; Laubenbacher, Rothley, Sitomer, Beanlands, Sawada, & Sutor, 1993; Picano, Parodi, Lattanzi, Sambuceti, Andrade, & Marzullo, 1994; Saraste, Koskenvuo, Knuuti, Toikka, Laine, & Niemi, 2001; Williams, Mullani, Jansen, & Anderson, 1994), thus their clinical use is limited (Dimitrow, 2003). In addition, PET and intracoronary Doppler flow wire involve radiation exposure, with inherent risk, environmental impact, and biohazard connected with use of ionizing testing (Picano, 2003a). In the last decade, the development of new ultrasound equipments and probes has made possible the noninvasive evaluation of coronary blood velocity by Doppler echocardiography, using a transthoracic approach. In this way, the peak diastolic coronary flow velocity reserve (CFVR) can be estimated as the ratio of the maximal (pharmacologically stimulated) to baseline (resting) diastolic coronary blood flow velocity peak measured from the Doppler tracings. Several studies have shown that peak diastolic CFVR, computed in the distal portion of the left anterior descending (LAD) coronary artery, correlates with CFR obtained by more invasive techniques. This provided a reliable and non invasive tool for the diagnosis of LAD coronary artery disease (Caiati et al., 1999b; Caiati, Montaldo, Zedda, Montisci, Ruscazio, & Lai, 1999c; Hozumi, Yoshida, Akasaka, Asami, Ogata, & Takagi, 1998; Koskenvuo et al., 2003; Saraste et al., 2001).

Vasospastic angina

ESC CardioMed ◽  
2018 ◽  
pp. 1427-1430
Author(s):  
Peter Ong ◽  
Udo Sechtem
Keyword(s):  
Kinase Inhibitors ◽  
Coronary Revascularization ◽  
Coronary Spasm ◽  
Underlying Mechanism ◽  
Vasospastic Angina ◽  
Coronary Microvascular Dysfunction ◽  
Channel Blockers ◽  
Short Acting ◽  
St Segment Elevation ◽  
Provocation Testing

The hallmark of vasospastic angina is angina at rest that promptly responds to short-acting nitrates. Classically, there is a preserved exercise capacity and the underlying mechanism is a focal occlusive spasm of the epicardial arteries with transient ST-segment elevation on the electrocardiogram (i.e. Prinzmetal’s, or variant angina). However, the clinical presentation of epicardial spasm may also comprise exercise-related symptoms. Intracoronary provocation testing with acetylcholine is the method of choice to establish the diagnosis and this can be performed with a good safety profile. Coronary spasm may occur in patients with normal or unobstructed coronary arteries but also in patients with epicardial stenoses and those with previous coronary revascularization. Distribution of epicardial spasm can be focal or diffuse and involve multiple locations. In European patients, diffuse spasm of the distal left anterior descending coronary artery is a frequent finding. Coronary spasm may also exist at the level of the coronary microcirculation which represents a form of coronary microvascular dysfunction. Despite good efficacy of calcium channel blockers and short-acting nitrates, a substantial number of patients have refractory symptoms. Apart from optimal risk factor control, emerging drugs for these patients include, for example, rho kinase inhibitors.

scholarly journals 995-17 Are Intracoronary Doppler Flow Velocity Measurements Accurate for Assessment of Coronary Flow Reserve?

1995 ◽  
Vol 25 (2) ◽  
pp. 321A-322A ◽  
Author(s):  
Nicolas W. Shammas ◽  
Venkata Thondapu ◽  
J. Antonio ◽  
G. Lopez ◽  
Michael D. Winniford ◽  
...  
Keyword(s):  
Flow Velocity ◽  
Coronary Flow Reserve ◽  
Coronary Flow ◽  
Velocity Measurements ◽  
Doppler Flow ◽  
Intracoronary Doppler ◽  
Flow Reserve

Diagnosis of coronary microvascular dysfunction in the clinic

2020 ◽  
Vol 116 (4) ◽  
pp. 841-855 ◽  
Author(s):  
Peter Ong ◽  
Basmah Safdar ◽  
Andreas Seitz ◽  
Astrid Hubert ◽  
John F Beltrame ◽  
...  
Keyword(s):  
Coronary Flow ◽  
Coronary Thrombosis ◽  
Coronary Spasm ◽  
Microvascular Dysfunction ◽  
Coronary Microcirculation ◽  
Coronary Microvascular Dysfunction ◽  
Human Beings ◽  
Transthoracic Doppler Echocardiography ◽  
Non Invasive ◽  
Flow Reserve

Abstract The coronary microcirculation plays a pivotal role in the regulation of coronary blood flow and cardiac metabolism. It can adapt to acute and chronic pathologic conditions such as coronary thrombosis or long-standing hypertension. Due to the fact that the coronary microcirculation cannot be visualized in human beings in vivo, its assessment remains challenging. Thus, the clinical importance of the coronary microcirculation is still often underestimated or even neglected. Depending on the clinical condition of the respective patient, several non-invasive (e.g. transthoracic Doppler-echocardiography assessing coronary flow velocity reserve, cardiac magnetic resonance imaging, positron emission tomography) and invasive methods (e.g. assessment of coronary flow reserve (CFR) and microvascular resistance (MVR) using adenosine, microvascular coronary spasm with acetylcholine) have been established for the assessment of coronary microvascular function. Individual patient characteristics, but certainly also local availability, methodical expertise and costs will influence which methods are being used for the diagnostic work-up (non-invasive and/or invasive assessment) in a patient with recurrent symptoms and suspected coronary microvascular dysfunction. Recently, the combined invasive assessment of coronary vasoconstrictor as well as vasodilator abnormalities has been titled interventional diagnostic procedure (IDP). It involves intracoronary acetylcholine testing for the detection of coronary spasm as well as CFR and MVR assessment in response to adenosine using a dedicated wire. Currently, the IDP represents the most comprehensive coronary vasomotor assessment. Studies using the IDP to better characterize the endotypes observed will hopefully facilitate development of tailored and effective treatments.

Coronary flow reserve in HOCM-patients – An intracoronary Doppler-catheter investigation

2004 ◽  
Vol 52 (S 1) ◽  
Author(s):  
J Litmathe ◽  
D Stosch ◽  
HG Klues ◽  
U Boeken ◽  
P Feindt ◽  
...  
Keyword(s):  
Coronary Flow Reserve ◽  
Coronary Flow ◽  
Intracoronary Doppler ◽  
Flow Reserve

Mechanisms of angina in patients with biopsy-proven viral myocarditis: insights from intracoronary acetylcholine testing

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Seitz ◽  
V Martinez Pereyra ◽  
A Hubert ◽  
K Klingel ◽  
R Bekeredjian ◽  
...  
Keyword(s):  
Coronary Arteries ◽  
Coronary Spasm ◽  
Viral Myocarditis ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Funding Source ◽  
Pathophysiological Mechanism ◽  
Ecg Changes ◽  
Ventricular Ejection Fraction ◽  
Microvascular Spasm

Abstract Background Patients with myocarditis often present with angina pectoris despite unobstructed coronary arteries. The underlying pathophysiological mechanism of angina in these patients remains to be elucidated. Coronary artery spasm is a well-known cause of angina in patients with unobstructed coronary arteries. In this study, we sought to assess the frequency of coronary vasomotor disorders in patients with biopsy-proven viral myocarditis. Methods In total, 700 consecutive patients who underwent endomyocardial biopsy for suspected myocarditis between 2008 and 2018 were retrospectively screened. Of these patients, viral myocarditis was confirmed in 303 patients defined as histological/immunohistological evidence of myocardial inflammation and presence of viral genome confirmed by PCR. Of these patients, 34 patients had angina despite unobstructed coronary arteries and underwent intracoronary acetylcholine (ACh) provocation testing in search of coronary spasm. Epicardial spasm was defined as acetylcholine-induced reproduction of the patient's symptoms associated with ischemic ECG changes and >90% epicardial vasoconstriction. Microvascular spasm was defined as symptom reproduction and ECG changes in the absence of significant epicardial vasoconstriction. Results Patients were 49±16 years old, 62% were male and left ventricular ejection fraction was 54±16%. Most frequent viruses were parvovirus B19 (PVB19, 59%) and human herpes virus 6 (HHV6, 26%), 2 patients had combined PVB19/HHV6 infection and 3 patients other herpesviruses (CMV, EBV, VZV). Epicardial spasm was observed in 10 patients (29%) during ACh testing and microvascular spasm was found in 11 patients (32%). The rate of coronary spasm (epicardial and microvascular) was higher in the PVB19 subgroup compared to HHV6 (80% vs. 33%, p=0.031). In particular, there was a higher prevalence of microvascular spasm in PVB19 compared to HHV6 (45% vs. 0%, p=0.018). Conclusion We observed a high prevalence of microvascular and epicardial spasm in patients with biopsy-proven viral myocarditis suggesting coronary spasm as a potential underlying mechanism for angina in these patients. Microvascular spasm was most often observed in patients with PVB19-associated myocarditis. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Robert-Bosch-Stiftung; Berthold-Leibinger-Stiftung

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