Coronary microvascular spasm causes myocardial ischemia in patients with vasospastic angina
Hongtao Sun, MD*,
Masahiro Mohri, MD, PhD*,*,
Hiroaki Shimokawa, MD, PhD*,
Makoto Usui, MD*,
Lemmy Urakami, MD* and
Akira Takeshita, MD, PhD*
* Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Figure 1 Representative coronary arteriograms and electrocardiograms (ECGs) of a 58-year-old female patient having both microvascular and epicardial spasm. Baseline coronary arteriogram of the left coronary artery and ECG were normal. Intracoronary acetylcholine (ACH) 30 µg induced chest pain, ST depression (V4 to V6) and lactate production, but no epicardial spasm. These ischemic symptoms and signs spontaneously subsided in approximately 4 min. Acetylcholine 100 µg provoked a high-degree hyperconstriction (spasm) at the middle portion of the left anterior descending artery (arrowhead), associated with chest pain and ST elevation (I, II, aVL, V3 to V6). Isosorbide dinitrate (ISDN) relieved angina and ischemic ECG changes, and coronary arteriogram showed normal coronary artery.
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Figure 2 Myocardial lactate extraction ratio (A) and coronary lumen diameter assessed by quantitative arteriography (B) at baseline (BSL), at submaximal and maximal doses of acetylcholine (ACH) and after isosorbide dinitrate (ISDN). Lactate extraction ratio was significantly different between groups (p < 0.01 by two-way analysis of variance) at the submaximal dose (p < 0.01 by ad-hoc t test). Lumen diameter is expressed as percentage of that after ISDN administration. Closed circles = Group 1 patients with evidence of microvascular spasm (MVS); open squares = Group 2 patients without evidence of MVS.
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