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The role of ergonovine provocation test on active vasodilator therapy
International Journal of Cardiology 167 (2013) e5–e7
Contents lists available at SciVerse ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
The role of ergonovine provocation test on active vasodilator therapy Soon Yong Suh, Seung Hwan Han ⁎, Kyounghoon Lee, Woong Chol Kang, Kwang Kon Koh, Tae Hoon Ahn, Eak Kyun Shin Department of Cardiology, Gachon University Gil Hospital, Incheon, Republic of Korea
a r t i c l e
i n f o
Article history: Received 10 December 2012 Accepted 18 January 2013 Available online 8 February 2013 Keywords: Vasospastic angina Ergonovine provocation test Intractable vasospastic angina
A coronary spasm is a transient and marked narrowing of the coronary artery lumen which limits coronary blood flow under resting conditions [1]. In general, prognosis in patients with coronary vasospastic angina is relatively satisfactory if adequately treated by vasodilators such as calcium-channel antagonists and nitrate derivatives. However some patients show intractable attacks of angina despite standard medical treatment. Intractable vasospastic angina can trigger acute coronary syndrome or sudden cardiac death, therefore these patients should receive more intensive medical treatment or implant cardioverter defibrillator [1–3]. A 51-year-old male visited our emergency room (ER) due to syncope. He was an ex-smoker and under anti-angina medications. Six years ago, he visited the ER due to chest pain and subsequent ventricular tachycardia. His coronary angiography (CAG) was normal and his ergonovine provocation test was positive. Therefore, he was managed with calcium channel blocker and nitrate. At present admission, we evaluate other causes of syncope including brain magnetic resonance imaging (MRI) with angiogram, but no specific findings are noted. Therefore, we decide to perform CAG with ergonovine provocation test again to evaluate the cause of syncope (induced by vasospasm and arrhythmia). After admission, we infuse intravenous nitrate and then taper intravenous nitrate for preparation of ergonovine provocation test. During tapering of intravenous nitrate, he complains of chest pain and his electrocardiogram (ECG) showed junctional rhythm and ST elevation on leads II, III, and aVF (Fig. 1). We infuse intravenous nitrate again and plan for a provocation test again on calcium channel blocker and intravenous nitrate. Baseline CAG shows no significant
⁎ Corresponding author at: Department of Cardiology, Gachon University, Gil Hospital, 1198 Guwol-dong, Namdong-gu, 405-760, Incheon, Republic of Korea. Tel.: +82 32 460 3054; fax: +82 32 469 1906. E-mail address: [email protected] (S.H. Han). 0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.01.021
luminal narrowing (Fig. 2). However, the ergonovine provocation test shows significant diffuse multi-vessel coronary artery spasm on active vasodilators (Fig. 3). We diagnose him of intractable vasospastic angina. We treat him with two calcium channel blockers, nitrate, molsidomine, and nicorandil. He is free from symptoms for 6 months after discharge. Most patients with vasospastic angina generally have a good prognosis with vasodilator therapy [4,5]. Moreover spontaneous remission is frequent in Western people with vasospastic angina and it's acceptable to discontinue treatment after the angina disappears. However, it is controversial in Asian coronary vasospastic angina patients [6]. Some patients are diagnosed of intractable vasospastic angina despite standard medical therapy. Several stimuli can provoke coronary vasospasm, but the highest sensitivity and specificity have been shown with ergonovine. In general recommendations of ergonovine provocation test, vasodilator therapy should be stopped for at least 72 h to detect accurate vasospasm. Until now, the role of ergonovine provocation test on active vasodilator medications is not well defined. In our current case, of interest, we perform the ergonovine provocation test even under angina medication. The ergonovine provocation test shows diffuse multi-vessel coronary artery spasm on active vasodilator therapy. We diagnose it as intractable vasospastic angina. Intractable vasospastic angina has the possibility to trigger acute coronary syndrome or sudden cardiac death. Therefore, intractable vasospastic angina patients should receive more intensive medical treatment, including combinations of several vasodilators and/or implantation of cardioverter defibrillator if needed, to ensure that adverse cardiac events following myocardial ischemia are avoided. In conclusion, ergonovine provocation test is a very useful tool to evaluate the efficacy of treatment for vasospastic angina and diagnose intractable vasospastic angina even under active vasodilator medications. References [1] Kusama Y, Kodani E, Nakagomi A, et al. J Nippon Med Sch 2011;78:4–12. [2] Park YM, Kang WC, Shin KC, et al. Repeated sudden cardiac death in coronary spasm: is IVUS helpful to decide treatment strategy? Int J Cardiol 2012;154:e57–9. [3] Murakami D, Negishi K, Yamamoto M, et al. Refractory coronary spastic angina may induce sudden cardiac death even in young patients under appropriate medication. Int J Cardiol 2011;153:e19–21. [4] Park YM, Han SH, Ko KP, et al. Diffuse multi-vessel coronary artery spasm: incidence and clinical prognosis. http://dx.doi.org/10.1016/j.ijcard.2011.12.106. [5] Yoo SY, Shin DH, Jeong JI, et al. Long-term prognosis and clinical characteristics of patients with variant angina. Korean Circ J 2008;38:651–8. [6] Sueda S, Kohno H, Fukuda H, et al. Limitations of medical therapy in patients with pure coronary spastic angina. Chest 2003;123:380–6.
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S.Y. Suh et al. / International Journal of Cardiology 167 (2013) e5–e7
Fig. 1. ECG during anginal attack. During tapering of intravenous nitrate for ergonovine provocation test, the patient complains of chest pain and his electrocardiogram showed junctional rhythm and ST elevation on leads II, III, and aVF.
Fig. 2. Baseline coronary angiogram. Baseline coronary angiogram shows no significant stenosis at coronary artery.
S.Y. Suh et al. / International Journal of Cardiology 167 (2013) e5–e7
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Fig. 3. Coronary angiogram during ergonovine provocation test on active vasodilator therapy. Ergonovine provocation test reveals diffuse multi-vessel spasm even under multiple vasodilator treatment.
Contents lists available at SciVerse ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
The role of ergonovine provocation test on active vasodilator therapy Soon Yong Suh, Seung Hwan Han ⁎, Kyounghoon Lee, Woong Chol Kang, Kwang Kon Koh, Tae Hoon Ahn, Eak Kyun Shin Department of Cardiology, Gachon University Gil Hospital, Incheon, Republic of Korea
a r t i c l e
i n f o
Article history: Received 10 December 2012 Accepted 18 January 2013 Available online 8 February 2013 Keywords: Vasospastic angina Ergonovine provocation test Intractable vasospastic angina
A coronary spasm is a transient and marked narrowing of the coronary artery lumen which limits coronary blood flow under resting conditions [1]. In general, prognosis in patients with coronary vasospastic angina is relatively satisfactory if adequately treated by vasodilators such as calcium-channel antagonists and nitrate derivatives. However some patients show intractable attacks of angina despite standard medical treatment. Intractable vasospastic angina can trigger acute coronary syndrome or sudden cardiac death, therefore these patients should receive more intensive medical treatment or implant cardioverter defibrillator [1–3]. A 51-year-old male visited our emergency room (ER) due to syncope. He was an ex-smoker and under anti-angina medications. Six years ago, he visited the ER due to chest pain and subsequent ventricular tachycardia. His coronary angiography (CAG) was normal and his ergonovine provocation test was positive. Therefore, he was managed with calcium channel blocker and nitrate. At present admission, we evaluate other causes of syncope including brain magnetic resonance imaging (MRI) with angiogram, but no specific findings are noted. Therefore, we decide to perform CAG with ergonovine provocation test again to evaluate the cause of syncope (induced by vasospasm and arrhythmia). After admission, we infuse intravenous nitrate and then taper intravenous nitrate for preparation of ergonovine provocation test. During tapering of intravenous nitrate, he complains of chest pain and his electrocardiogram (ECG) showed junctional rhythm and ST elevation on leads II, III, and aVF (Fig. 1). We infuse intravenous nitrate again and plan for a provocation test again on calcium channel blocker and intravenous nitrate. Baseline CAG shows no significant
⁎ Corresponding author at: Department of Cardiology, Gachon University, Gil Hospital, 1198 Guwol-dong, Namdong-gu, 405-760, Incheon, Republic of Korea. Tel.: +82 32 460 3054; fax: +82 32 469 1906. E-mail address: [email protected] (S.H. Han). 0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.01.021
luminal narrowing (Fig. 2). However, the ergonovine provocation test shows significant diffuse multi-vessel coronary artery spasm on active vasodilators (Fig. 3). We diagnose him of intractable vasospastic angina. We treat him with two calcium channel blockers, nitrate, molsidomine, and nicorandil. He is free from symptoms for 6 months after discharge. Most patients with vasospastic angina generally have a good prognosis with vasodilator therapy [4,5]. Moreover spontaneous remission is frequent in Western people with vasospastic angina and it's acceptable to discontinue treatment after the angina disappears. However, it is controversial in Asian coronary vasospastic angina patients [6]. Some patients are diagnosed of intractable vasospastic angina despite standard medical therapy. Several stimuli can provoke coronary vasospasm, but the highest sensitivity and specificity have been shown with ergonovine. In general recommendations of ergonovine provocation test, vasodilator therapy should be stopped for at least 72 h to detect accurate vasospasm. Until now, the role of ergonovine provocation test on active vasodilator medications is not well defined. In our current case, of interest, we perform the ergonovine provocation test even under angina medication. The ergonovine provocation test shows diffuse multi-vessel coronary artery spasm on active vasodilator therapy. We diagnose it as intractable vasospastic angina. Intractable vasospastic angina has the possibility to trigger acute coronary syndrome or sudden cardiac death. Therefore, intractable vasospastic angina patients should receive more intensive medical treatment, including combinations of several vasodilators and/or implantation of cardioverter defibrillator if needed, to ensure that adverse cardiac events following myocardial ischemia are avoided. In conclusion, ergonovine provocation test is a very useful tool to evaluate the efficacy of treatment for vasospastic angina and diagnose intractable vasospastic angina even under active vasodilator medications. References [1] Kusama Y, Kodani E, Nakagomi A, et al. J Nippon Med Sch 2011;78:4–12. [2] Park YM, Kang WC, Shin KC, et al. Repeated sudden cardiac death in coronary spasm: is IVUS helpful to decide treatment strategy? Int J Cardiol 2012;154:e57–9. [3] Murakami D, Negishi K, Yamamoto M, et al. Refractory coronary spastic angina may induce sudden cardiac death even in young patients under appropriate medication. Int J Cardiol 2011;153:e19–21. [4] Park YM, Han SH, Ko KP, et al. Diffuse multi-vessel coronary artery spasm: incidence and clinical prognosis. http://dx.doi.org/10.1016/j.ijcard.2011.12.106. [5] Yoo SY, Shin DH, Jeong JI, et al. Long-term prognosis and clinical characteristics of patients with variant angina. Korean Circ J 2008;38:651–8. [6] Sueda S, Kohno H, Fukuda H, et al. Limitations of medical therapy in patients with pure coronary spastic angina. Chest 2003;123:380–6.
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S.Y. Suh et al. / International Journal of Cardiology 167 (2013) e5–e7
Fig. 1. ECG during anginal attack. During tapering of intravenous nitrate for ergonovine provocation test, the patient complains of chest pain and his electrocardiogram showed junctional rhythm and ST elevation on leads II, III, and aVF.
Fig. 2. Baseline coronary angiogram. Baseline coronary angiogram shows no significant stenosis at coronary artery.
S.Y. Suh et al. / International Journal of Cardiology 167 (2013) e5–e7
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Fig. 3. Coronary angiogram during ergonovine provocation test on active vasodilator therapy. Ergonovine provocation test reveals diffuse multi-vessel spasm even under multiple vasodilator treatment.