Cardiac arrest and sudden unexpected death in variant angina: Complications of coronary spasm that can occur in the absence of severe organic coronary stenosis

doi:10.1016/0002-8703(93)90108-L

American Heart Journal

Volume 125, Issue 4, April 1993, Pages 1011-1017

https://doi.org/10.1016/0002-8703(93)90108-L Get rights and content

Abstract

Experiences in 81 patients with variant angina were reviewed with the goal of determining which clinical features were associated with the greatest risk of angina-linked cardiac arrest (13 patients) or sudden unexpected death (9 patients). The risk of occurrence of one of these actually or potentially fatal events was approximately tripled by the presence of either a history of angina-linked syncope or documentation of serious arrhythmia complicating attacks. An unexpected finding was that the risk was increased 1.5-fold by the absence of high-grade organic coronary stenosis. Cardiac arrest and sudden death are important risks of variant angina, which can occur without the presence of severe organic coronary stenosis. These risks can be reduced by adequate vasodilator therapy that includes a calcium channel blocker.

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Coronary provocation testing is an essential diagnostic procedure when evaluating vasospastic angina. Invasive methods using acetylcholine or ergonovine are considered the current gold standard. Despite efforts from global cardiovascular institutions, current protocols vary in dosage, administration time, and procedural approach. In addition, concerns over the specificity of findings and potential complications have limited routine uptake of this procedure in clinical practice. This systematic review evaluates current diagnostic protocols, focusing on invasive provocation testing. We included studies using intracoronary provocation testing with acetylcholine or ergonovine for the assessment of coronary artery vasospasm that detailed specific elements of the procedure (dosage, administration time, etc.) and included $\geq$ 50 patients. A total of 28 articles met strict inclusion criteria. Our review highlights the heterogeneity between current diagnostic protocols for invasive provocation testing. We believe standardization of a diagnostic protocol will encourage both current and future cardiologists to incorporate such procedures in the evaluation of variant angina.
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Up to 65% of women and approximately 30% of men have ischemia with no obstructive coronary artery disease (CAD; commonly known as INOCA) on invasive coronary angiography performed for stable angina. INOCA can be due to coronary microvascular dysfunction or coronary vasospasm. Despite the absence of obstructive CAD, those with INOCA have an increased risk of all-cause mortality and adverse outcomes, including recurrent angina and cardiovascular events. These patients often undergo repeat testing, including cardiac catheterization, resulting in lifetime healthcare costs that rival those for obstructive CAD. Patients with INOCA often remain undiagnosed and untreated. This review discusses the symptoms and prognosis of INOCA, offers a systematic approach to the diagnostic evaluation of these patients, and summarizes therapeutic management, including tailored therapy according to underlying pathophysiological mechanisms.
Jusqu’à 65 % des femmes et environ 30 % des hommes présentent une ischémie sans coronaropathie obstructive (INOCA [ischemia with no obstructive coronary artery disease]) révélée à la faveur d’une angiographie coronarienne invasive réalisée pour une angine stable. L’INOCA peut être attribuable à une dysfonction microvasculaire coronaire ou à un vasospasme coronaire. Malgré l’absence de coronaropathie obstructive, les patients atteints d’une INOCA présentent un risque accru de décès toutes causes confondues et d’événements indésirables, notamment l’angine récurrente et des événements cardiovasculaires. Ces patients sont souvent soumis à des examens répétés, dont le cathétérisme cardiaque, ce qui représente des dépenses de santé à vie qui rivalisent avec celles associées aux coronaropathies obstructives. Dans bien des cas, l’INOCA échappe au diagnostic et n’est pas traité. Dans le présent article de synthèse, nous nous penchons sur les symptômes et le pronostic de l’INOCA. Nous proposons une méthode systématique d’évaluation diagnostique de ces patients et résumons les modalités de sa prise en charge thérapeutique, notamment un traitement adapté aux mécanismes physiopathologiques sous-jacents.
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Alcohol intake is one of the triggers of out-of-hospital cardiac arrest (OHCA) and is associated with survival outcomes due to its relationship with cardiovascular conditions such as variant angina and arrhythmias. The aim of this study was to evaluate the association between alcohol intake shortly before cardiac arrest and survival outcomes after OHCA.
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Vasospastic angina is an infrequent underlying cause of angina and is under-diagnosed. Ergonovine provocation tests can be performed via intravenous or intracoronary injections. Although the safety profile of intracoronary injection has been well documented, no study has yet compared the intracoronary and intravenous injections regarding the positivity rate of the test.
This study sought to compare the positivity rate of intravenous versus intracoronary injection of ergonovine in the diagnosis of vasospastic angina.
Between January 2010 and February 2018, 427 patients with suspected vasospastic angina underwent an ergonovine provocation test in 2 tertiary hospitals in France and were retrospectively included in this study. Injection was performed via the intravenous or the intracoronary route. The primary endpoint was the positivity rate of the test. Propensity score matching was used to account for confounding factors.
427 patients were included in the study. Mean age was 60.3 (+/- 12.4) years. There were 247 (58%) females and 97 (23%) smokers. The intracoronary route was used in 199 (47%) patients. The indication for the test was acute coronary syndrome for 121 (28%). No rhythmic complications or deaths were reported. After propensity-matching, the baseline characteristics of the 2 groups (148 patients in each) were comparable. The positivity rate was 24% in the intracoronary group and 9% in the intravenous group (OR [95%CI]: 3.2 [1.6, 6.4]).
Intracoronary injection of ergonovine is safe and associated with a positivity rate of the test three times higher compared to intravenous injection.
Le spasme coronaire est une cause rare d'angor, et est sous-diagnostiqué. L'injection d'ergonovine peut être réalisée par voie intraveineuse ou intra coronaire. Le profil de sécurité de l'injection coronaire est largement connu. Cependant, il n'existe pas d’étude comparant la rentabilité diagnostique de ces deux voies d'injection. Cette étude compare le taux de positivité de l'injection d'ergonovine par voie veineuse et par voie coronaire dans le diagnostic de l'angor vasospastique.
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Citation Excerpt :
Although the complete pathophysiology behind coronary vasospasm is unknown, vasospasm leads to transient myocardial ischemia and can cause devastating cardiac abnormalities, including ventricular arrhythmias, asystole, and third-degree atrioventricular block. These serious complications can occur in patients without evidence of severe organic coronary disease.2 Traditional risk factors include female sex, smoking, cocaine use, and Japanese heritage.

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Cardiac arrest and sudden unexpected death in variant angina: Complications of coronary spasm that can occur in the absence of severe organic coronary stenosis

Abstract

Am Heart J

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Med

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

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Am J Cardiol

Am J Cardiol

Am Heart J

Am Heart J

Am J Cardiol

J Am Coll Cardiol

Sudden coronary death in Glasgow: nature and frequency of acute coronary lesions

Br Heart J

Thrombolysis and acute coronary-artery lesions in sudden cardiac ischemic death

N Engl J Med

Angiographic findings and prognostic indicators in patients resuscitated from sudden cardiac death

Circulation

Clinical features and prognosis of patients with out of hospital cardiac arrest and a normal electrophysiologic study

J Am Coll Cardiol

Coronary artery size during life: a cinearteriographic study

Radiology

Angiographic determination of disease-produced alterations in vasomotor tone in large coronary arteries

Can J Cardiol

Clinical characteristics associated with myocardial infarction, arrhythmias, and sudden death in patients with vasospastic angina

Circulation

Long-term prognosis of patients with variant angina

Circulation

The effects of medical treatment on long-term prognosis of variant angina pectoris

J Cardiogr

Long-term prognosis for patients with variant angina and influential factors

Circulation