maco har log P y: r O la u p c e n s a A Fumimaro Takatsu, Cardiol Pharmacol 2015, 4:3 v c o c i e d r s Open Access a s Cardiovascular Pharmacology: DOI: 10.4172/2329-6607.1000143 C ISSN: 2329-6607 Letter to Editor OpenOpen Access Access Variant Angina: Why do you Ignore Spasm of Coronary Arteries? Fumimaro Takatsu MD* Department of Cardiology, Takatsu Naika Junkankika, 2-4-7 Mikawaanjo-Hommachi, Anjo, Aichi, Japan Introduction perform provocation of spasm; if possible (once the patient returned to a ward, I explain on the vasospasm and get written informed consent), Many authors reported on variant (form of) angina (Prinzmetal’s before the patient and families leave the hospital because almost all Variant Angina, vasospastic angina) till 1990s on the various aspects of of patients and families cannot realize electrocardiographic findings this disease. However, in this century, articles on this very important and would not have medications. Moreover, although not so frequent, disease have become very few. One reason of this apparent ignorance some patients with chest discomfort only on effort have no significant of vasospastic angina may be caused by a report by Cianflone et al. in coronary narrowing have vasospasm. 2000 [1], in which they studied only 34 patients and concluded that vasospasm is much less in Caucasian peoples. A scientific research, Complications especially in clinical medicine, at least more than several hundred Coronary vasospasm, of course, if prolonged, can cause acute patients must be studied for some conclusion. Thus, I feel, their result myocardial infarction by itself or by causing intraluminal thrombus or is very questionable and responsibility of American Heart Association rupture of minor atherosclerotic plaque. And in this respect, presence to have adopted such poor report is very large to practical medicine and of narrowing, even less than 50%, can be dangerous [9]. For preventing all natural sciences. Why cardiologists nowadays have no concern to such prolonged spasm, it is very important to teach patients with this variant angina? As I describe below, diagnosis and treatment of patients disease to have sublingual nitrate within their reach and to use it even with vasospasm are very important. In reality, it is sure that in some if chest symptom is very mild. Prolonged spasm, other than acute subjects it is very difficult to prove or deny the presence of coronary coronary syndrome, causes fatal arrhythmias; ventricular fibrillation, vasospasm. However, as coronary vasospasm, even in the absence of ventricular tachycardia, completes atrioventricular block and electro- significant coronary narrowings, triggers acute myocardial infarction mechanical dissociation [10-12]. In Japan, utilization of implantable and fatal arrhythmias, we must be very careful to deny vasospasm. cardiac defibrillator in cases with ventricular fibrillation or ventricular One of important problem is in medical treatment. Drugs to subjects tachycardia on spasm is discussed. However, I myself, consider that with vasospasm are different from those patients without vasospasm enough medical treatment would suppress such serious arrhythmias. (i,e. propranolol is effective to subjects with effort angina but very hazardous for patients with vasospastic angina). I am afraid ignorance Spasm associated with coronary narrowing or occlusion of vasospasm will cause major adverse cardiac events in many patients. Since the end of 1970s intracoronary thrombolysis was introduced History and Various Aspects for the treatment of subjects suffering acute myocardial infarction or unstable angina; next, emergency percutaneous coronary angioplasty In 1959, Prinzmetal et al. reported 32 cases with ST elevation and in these 20 years emergency stent is done routinely. Of course, on chest pain and described one autopsy case with severe coronary emergency bypass surgery has been done if indicated. Many of these atherosclerosis. Moreover, in this report, they reported that some patients have chest discomfort at rest or during sleep as symptoms patients showed ventricular tachycardia or complete heart block during of severe coronary narrowing. It is very important to resolve severe ST elevation and suggested a role of vasospasm [2]. Prognosis of these coronary narrowing(s) or occlusion as soon as possible. However, we patients was worse than those with ST depression on chest discomfort should not rule out the possibility of coronary vasospasm because chest and this symptom was called as Prinzmetal’s Variant Angina. A report symptom not related to effort may be caused by spasm [13,14]. Except of autopsy of 23 cases with such symptoms [3] showed severe coronary for patients with acute coronary syndrome, many patients with chest atherosclerosis in 3 patients. At present, 3 these patients are thought discomfort only on exercise in mornings have coronary vasospasm to have unstable angina. However, in this era, cardiologists had only [15], although they also may have severe coronary narrowing. Chest electrocardiogram and further evaluation of this symptom without discomfort on sudden cold exposure is one of specific symptoms of severe coronary atherosclerosis was impossible. In the beginning of this disease. 1970’s Mason F Sones began selective coronary arteriography [4]. And Oliva et al. [5] incidentally found spontaneous coronary spasm Consequently, if possible, we must perform provocation of spasm during coronary arteriography at site without significant narrowing. several months after emergency treatment of critical coronary lesions In 1973, Cheng et al. [6] reported 4 cases without significant coronary in all patients. Thus, if such patients had bypass surgery, cardiologists narrowing and had spasm. They called these cases as “variant of the variant”. In 1977, Schroeder et al. [7] and Heupler et al. [8] reported method of provocation of coronary vasospasm with ergonovine maleate during coronary arteriography and proved the cause of transient *Corresponding author: Fumimaro Takatsu MD, *Department of Cardiology, Takatsu Naika Junkankika, 2-4-7 Mikawaanjo-Hommachi, Anjo, Aichi, Japan, Tel: ST elevation in patients without significant coronary narrowing as +81-566-71-3335; Fax: +81-566-71-3330; E-mail: [email protected] transient vasospasm. And in these cases without significant coronary atherosclerosis, prognosis was thought not so poor if they have optimal Received May 07, 2015; Accepted May 20, 2015; Published May 25, 2015 medical treatment. Nowadays, emergency coronary angiography is Citation: Fumimaro Takatsu MD (2015) Variant Angina: Why do you Ignore Spasm of done if chest pain with ST elevation is observed in a patient even if chest Coronary Arteries?. Cardiol Pharmacol 4: 143. doi:10.4172/2329-6607.1000143 symptom and ST elevation are subsided spontaneously or with nitrate. Copyright: © 2015 Fumimaro Takatsu MD et al. This is an open-access article dis- If no significant coronary stenosis was found, the presence of coronary tributed under the terms of the Creative Commons Attribution License, which per- mits unrestricted use, distribution, and reproduction in any medium, provided the vasospasm is definite for cardiologists. However, I, myself, ordinarily original author and source are credited. Cardiol Pharmacol ISSN: 2329-6607 CPO, an open access journal Volume 4 • Issue 3 • 1000143 Citation: Fumimaro Takatsu MD (2015) Variant Angina: Why do you Ignore Spasm of Coronary Arteries?. Cardiol Pharmacol 4: 143. doi:10.4172/2329- 6607.1000143 Page 2 of 4 must alarm cardiac surgeons that, if possible, on the angiographic Ergonovine : ergnovine maleate or methyl ergonovine study to confirm patency of the bypass, provocation of spasm should be performed; almost all cardiac surgeons have no concern on vasospasm. In 1977 Schroeder et al. [7] first reported 57 cases and proved Of course, as provocative test is, if it is done by immature cardiologists transient occlusion of coronary artery in 13 patients using ergonovine dangerous [16], experienced cardiologists should be present in the maleate during diagnostic coronary angiography. In their report, catheterization room and we must check function of direct current provocation of spasm was performed after ordinary angiography countershock tool just before angiographic study. and left ventriculogaphy using sublingual nitroglycerin. Amount of ergonovine was 0.05 mg at first and if no spasm induced, 0.10 mg Diagnosis was added and finally 0.15 mg was injected. Heupler et al. [8] proved vasospasm with intra-aortic ergonovine maleate 0.1- 0.2 mg (maximal I experienced over 4,000 patients with coronary vasospasm. 0.3 mg in total). Among 98 patients, 11 showed spasm. One of these However, some subjects who have chest discomfort suggestive patients had old myocardial infarction and they reported serious of vasospastic angina show no spasm even with ergonovine or arrhythmias (ventricular tachycardia or complete heart block) in 7 acetylcholine. And it is not so rare that in the first coronary angiography subjects. I occasionally discuss with cardiologists who consider that no vasospasm was induced, angiography several years later proves provocation of spasm after routine diagnostic coronary arteriography vasospasm. I know at least 2 patients whose electrography, incidentally is not useful because nitrate used at angiographic study might hinder showed ST elevation on chest discomfort whose repeated angiographies provocative test. It is very erroneous: cardiologists should read reports could not prove vasospasm.