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CLINICAL RESEARCH: CORONARY SPASM

Coronary Artery Spasm as a Frequent Cause of Acute Coronary Syndrome

The CASPAR (Coronary Artery Spasm in Patients With Acute Coronary Syndrome) Study

Department of Cardiology and Pulmology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.

Manuscript received November 20, 2007; revised manuscript received April 24, 2008, accepted April 29, 2008.

^_* Reprint requests and correspondence: Dr. Udo Sechtem, Robert-Bosch-Krankenhaus, Department of Cardiology and Pulmology, Auerbachstrasse 110, 70376 Stuttgart, Germany. (Email: Udo.Sechtem{at}rbk.de).

Objectives: This study was conducted to clarify the incidence of coronary spasm in emergency patients with suspected acute coronary syndrome (ACS) and acute chest pain at rest.

Background: Chest pain at rest is a frequent symptom in the emergency room. Acute coronary syndrome is suspected in patients with elevation of cardiac markers, ischemic electrocardiographic changes, or simply typical clinical symptoms of unstable (usually resting) angina. However, of all patients with suspected ACS who undergo coronary angiography, up to 30% have nonobstructed coronary arteries. We sought to clarify how many of these patients suffer from coronary spasm as a possible cause of their chest pain.

Methods: In a prospective study from June to December 2006, all patients with suspected ACS who underwent coronary angiography and had no culprit lesion underwent intracoronary provocation with acetylcholine. The ACH testing was considered positive at a vasoconstriction of 75% relative to the diameter after intracoronary nitroglycerine when the initially reported symptoms could be reproduced.

Results: Of 488 consecutive patients, 138 had no culprit lesion (28%). Twenty-two were found to have another diagnosis. The ACH testing was performed in 86 of the remaining 116 patients. In 42 patients, coronary spasm was verified (49%).

Conclusions: Every fourth patient with ACS had no culprit lesion. Coronary spasm could be documented in nearly 50% of the patients tested by ACH. Coronary spasm is a frequent cause of ACS and should regularly be considered as a differential diagnosis.

Key Words: acute coronary syndrome • coronary artery spasm • acetylcholine • culprit lesion • chest pain

Abbreviations and Acronyms   ACH = acetylcholine   ACS = acute coronary syndrome   ECG = electrocardiogram   LCA = left coronary artery   NSTEMI = non–ST-segment elevation myocardial infarction   STEMI = ST-segment elevation myocardial infarction   UAP = unstable angina pectoris

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