Spontaneous Vascular Hypertonus

CORONARY ARTERY SPASM

Dr.Myron Prinzmetal(1908-1987)

Atilio Maseri

Kounis syndrome ??• Concurrence of ACS with allergic or hypersenstivity reactions.

Introduction

• Angina can occur during increased oxygen demand or at rest or on ordinary physical activity.• Hypertonus of a diseased vessel can produce symptoms

of angina – variant angina or Prinzmetal angina.• Spasm of normal coronaries causing angina – Maseri

Angina.

Prinzmetal M, Angina pectoris. I. A variant form of angina pectoris; preliminary report. Am J Med. 1959; 27: 375-388.Maseri A, Coronary artery spasm as a cause of acute myocardial ischemia in man. Chest. 1975; 68: 625-633.

Epidemiology• Greater in the Japanese Population.( 40%)• Multiple spasms on provocative testing (≥2) in Japanese -

24.3%,Taiwanese 19.3%,Caucasians 7.5%.• More in men than in women.• Most between 40 to 70 years of age.

JCS Joint Working Group. Japanese Circulation Society of Guidelines for Diagnosis and Treatment of Patients with Vasospastic Angina (Coronary Spastic Angina) (JCS 2008): digest version. Cir J. 2010; 74: 1745-1762.

Risk factors• Smoking (more in younger) 45-75%• Age• HsCRP• Physical stress• Magnesium deficiency• Hyperventilation• Valsalva maneuver• Cocaine administration• Sympathomimmetics• Ergot alkaloids • Catheter induced

Precipitating factors

Takaoka K, Comparison of the risk factors for coronary artery spasm with those for organic stenosis in a Japanese population: role of cigarette smoking. Int J Cardiol. 2000; 72: 121-126Sugiishi M, Cigarette smoking is a major risk factor for coronary spasm. Circulation. 1993; 87: 76-79.

Pathogenesis • Poorly understood• Multifactorial• Coronary vascular smooth muscle hyperactivity is the main

substrate for CAS.

Ming-Jui Hung et al. Coronary Artery Spasm: Review and Update Intern J of Med Sci 2014; 11(11): 1161-1171. doi: 10.7150/ijms.9623

Clinical Features• CAS related ischemic heart diseases comprise a wide spectrum

of myocardial ischemic syndromes from silent myocardial ischemia to unstable angina , acute myocardial infarction and sudden death.• Usually occurs in Midnight to early morning.• Circadian variations of the tone of the coronary arteries.• ST segment depression more than ST segment elevation.• Associated with all arrhythmias – sinus bradycardia, sinus

arrest, complete AV block, paroxysmal AF,VPCs, VT, VF, asystole.• Activated platelets may aggravate CAS.

Ming-Jui Hung et al. Coronary Artery Spasm: Review and Update International Journal of Medical Sciences 2014; 11(11): 1161-1171. doi: 10.7150/ijms.9623

Low 0-2 - 2.5%Intermediate 3-5 – 7.0%

High >6 – 13%

JCSA scoreJapanese Coronary Spasm Association Score

Journal of the American College of Cardiology Sep 2013, 62 (13) 1144-1153;

Diagnosis• Coronary angiography with provocative testing is the only

method for diagnosing CAS.• Provoked CAS is defined as a reduction of >50%,>70%,>75%

or>90% in luminal diameter with accompanying symptoms and/or ischemic changes compared with postintracoronary nitroglycerin.

• IC Methylergonovine and Acetylcholine cause smooth muscle cell contraction in the setting of endothelial dysfunction.

• A negative test does not always exclude CAS.• Hyperventilation provocation test

Ming-Jui Hung et al. Coronary Artery Spasm: Review and Update International Journal of Medical Sciences 2014; 11(11): 1161-1171. doi: 10.7150/ijms.9623

Treatment • Calcium channel blockers• Nitrates • Nicorandil• Fasudil• Fluvastatin• Drug refractory – 20% cases.• Stenting > CABG – only in obstructive coronary disease and

ACS• ICDS ? For arrhythmias

Ming-Jui Hung et al. Coronary Artery Spasm: Review and Update International Journal of Medical Sciences 2014; 11(11): 1161-1171. doi: 10.7150/ijms.9623