Coronary Arterial Spasm

Coronary Arterial Spasm+: M. A.

I

DEMANY, M.D.;lH-

T HAS BEE

A.

H. A. CLeveLand, Ohio

TAMBE, M.D'-X-·X· AND

STATED THAT CORONARY

arterial spasm is the responsible factor for the attack of angina pectoris, whether , organic vascular disease is present or not. ·2 This type of spasm was thought to be the precipitating factor in anginal attacks occurring at rest, particularly those unas.c;ociated with tachycardia or with any other apparent. reason for diminished coronary flow or mcreased cardiac work. Coronary spac;m was also held responsible for the OCcurrence of angina pectoris and sudden de~th of individuals in whom no coronary lesIons could be found at necropsy. Spasm of the right coronary artery has also been cited ac; the cause of the anO'inal paroxysm following the injection of ice water: In .a recent case report,3 ST segment elevatIOn 10 leads 2, 3 and AVF was noted under these circ~mstances. Unfortunately, there was no angIOgraphic evaluation of the coronary vessels. C?ronary cinearteriography has made possIble the demo t . ns ratIon of coronary ar. t~flal spasm a~d of its relief by nitrites. This paper deals wIth the OCCurrence of spasm in a . coronary . senes of 750 coronary cinear~eflograms. Three cases will be described In more deta'l b . I ecause they give rea,>onable support to the sugge tions advanced above. . MATERIAL ANn METHODS

Dunng the last three "ears the author" have pe f d 7 ., < ., I' ~rme 50 coronary cinearteriograms, usmg the sa m e tech~ic described by Sones and Shire,,' but .t h I .,' WI on y one . . modIficatIOn: dlatnzoate methyl I . g ucamme (R enografin) was substituted f .. d' " or latnzoate ' H sod /Um (. 'vpaque) t0 ac h'leVe coronarv . :, opacIfication. Both Coronar)' art' , I' enes werc vrsua '" lzed before . and after .subl'mgua I a d mmlstratlOn of mtroglycerin gr 1/150. *From. the Car?iovascular Labor:ltory St. Vincent Chanty HospItal. ' **Associates. tDircctor.

714

ZCVIMERMAN

M.ll., F.C.C.P.t

Coronary cinearteriography was carried out as an integral part of cardiac catheterization in every patient age 16 or oyer referred to the cardiac laboratory. Table I gives the breakdown of this series of cases into a fcw broad diagnostic categories. Spasm was onsidered to be pre ent when definite luminal narrowing of a coronary arterial trunk had di 'appeared two minute after sublingual administration of nitroglycerin. RESULTS

Coronary spasm was ob erved only on seven occasions: once in the left coronary main trunk; once in its anterior descendin 0branch; and the remaining five times in the main trunk of the right coronary artery, The degree of narrowin CT was moderate in five patients and marked in the two othel ~ who experienced severe retrosternal pain at that time, Four pati nts denied any symptom in the short period of time preceding relief of th spasm by nitroglycerin, The three other experienced an attack of chest pain which had all the features of coronary in. ufficiency. Thes will be reported in more detail below. The tip of the catheter was ,'cry probably in two cases and certainl~' in a third on , the factor that initiated the spasm, as th narrowed segment involved the proximal portion of the coronary trunk into which it had been introduced. In two case~, the narrowed arterial seg_ ment was located much further than the catheter tip (distal third of right coronary artery m a in trunk) . In another instance (case 4) spasm occurred hefore the coronary arteries could be catheterized, and in the last patient, while the cathet I' tip was floating in the ascending aorta. Severe, widespread coronary artery di case was demonstrated in two of these even patients; n ithcr on complained of ch ,t

Volumt 53. No, 6 Junt, 1968

CORO>
pain at the time the spasm was \'isualiz d. The pastic narrowing disappeared promptly after nitroglycerin, but thc multiple luminal narrowings due to coronary disea~e were more promin nt than evcr. :\ moderate luminal irregularity of quc tionable hemodynamic significance wa found in another patient (ca:e 3). The left ventricular end-diastolic prc,sure was slightly elevated in onc patient I case 6); but it was normal in th other six. one of these :ev n paticnts had e\'idence for congenital, rhcumatic, luetic and hypertensive heart disease or cor pulmonale.

d'snilwd as a pres 'ur located behind the sternUIlI \\'ith(llll radiation, During these attacks. he would ~\\'l'al profusely and was afraid to movc, lie had b 'CII treated \\'ilh sedatives analgesics and nan'otic' withoul much SlIcce's, Surprisingly. COI'Ollal'y \'a-'odilalOrs had not becn gh'cn a trial. During manipulation of a Positrol-le one coronal'y catheter in the vicinity of the I ft coronary Ostium. its tip snapp"d into the main trunk of the anCI'y and lodged itself into the proximal sc Tl11elll of it, diagonal branch. A few seconds laler, the patient complain d of chest pain which had all the charaClel"istics of anginal paroxysm. including its rapid and complete relief by nitroglycerin. Coronary cineaneriography revealed only mild luminal il'l'eO'ularity of the middle pOl'lion of the right coronary anery main trunk, i\. '13-yeal'-0Id "'hite man had, during thc previous two years. experi need occasional anacks of pressure-like or con tricting retrosternal pain induced by elTon 01' emotion and relieved Cluickly by I'C t or nilroO'lycerin, Onc y 'ar prior ro this 'xamination. he had been hospiraliled cl'ewherc fOl' 15 days because of a imilar attack of chest pain bUt accompanied by nau'ea, emcsis and pro-

3 A 55-ycar-old Callca~ian was rt'fplTl'd for corunary cincancriography becall~e of ('pi~odp' of reuostcrnal pain induc'd by cmOliona I UpSClS. Thcse attacks had becolllC progressiv('l y more frequcnt over a pcriod of \8 months <.Il1rin~ which he had bccn subjccted to l1l1 IIslla 1 tellSion because of severe professional dilTicuhies. The pain was

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FIGURE

later. NOle the trem 'nclous elevati, n of the S-T seg-ment.

Diseases of lhe Chest

DEMAN Y, TAMBE AND ZIMME RMA

D). During the next five minutes , both coronary arteries were sele tively opacifie d. No narrO\\·ing> or obstruc tions could be demons trated. The huge domina nt I'ighl coronar y artery, in particular, had a very smoot h IUlllen (Fig IE and F). Serial determi nations of serum g lu tam i c oxaloacetic transam inase and laclic dehydro genase showed no elevatio n and da i I y electroc ardiogra ms reo mained normal.

fuse sweating. Meperid ine (Demer ol) relieved the pain. He was later told that the electroc ardiogram taken during the attack had shown evidence of injury to the heart muscle; howeve r, neither the electroc ardiogra m nor the blood tests h.ad supporte d a diagnosis of myocard ial infarclion unequivocally. . At the time of the present admissi on, the physIcal ex~mination, chest x-ray film, EeG and vectorcardIOgram were not remarka ble. He seemed rather highly emotion al; it was the impress ion of several observers that he tried to appear cheerful while disgu'" Ismg a great deal of fear. WIllie . a Stones. catheter was advance d easily in the right Jrachlal artery to per form coronar y cmeane . ' nography, the patient complai ned of severe retrosternal pressure . H e was sweating profusel y felt nauseated. and th ' ' of en vomited a small amount cofIear Ati e th same . st flUid d d time, the ST segmen t 'dl an ar . ead III of the EeG was rising rapI y and marked l dropped from 10 y an d the arterial pressure IA and B). 8/70 to 80/58 mm Hg (Fig

A 32-year -old while Illan was referred for investigat ion because of several episodes of rell'osternal pain, describe d as a squeezin g sensation. The allacks usually occurre d in the morning and lasted from 15 to 45 minutes . He would rest during that period; no vasodila tors were taken. After persiste nt question ing, he admitte d to have had "person al problem s," but he had never been followed by a psychia trist. During one of Ihe spells the electroc ardiogra m showed T wave inversio n in leads 2, 3 and AVF: on another occasion , second degree AV block. Wencke bach Iype was found. There was neither electric al nor enzyma tic evidenc e for myocard ial necrosis. During coronar y cineane riograph y, he became very frighlen ed, despite the usual amount of premed ication. An injectio n was made in the right coronar y artery w hi c h appeare d normal

Two aft er bl" nitroglycminutes erin I/ su mgual adminis tration of descend ra . gr 150 the ST segment began to disappeare~ldly t07ard the baseline and the pain terial pressur~omp ~t2e8IY/. By that time, the arwas 78 mm Hg (Fig Ie and ,

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Ftc.IC FIGURE IC (Case 4-)' Ele I d' FIG. 10 lingual nitroglycerin. 'The S~To~:rml ogr~m (Ie~d III) aortic pressure recorded two minutes later afler subgram (lead I I I) aortic ressure ~g ent IS startmg. to come down. FIGURE 1D (Case 4-): Electroc ardiowille had to the bas::li:C: while ~hcof(le~ three minutes ~ft~r tracin.g Fig !C. he SoT segment has e aortic pressure has srgndil'antly 1'1senoffollo\\'lI1 g' I1Itroglycerin.

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Volume )3•• o. 6 June. 1968

CORO. 'ARY ARTERIAL SPASM

(Fig 2A). At that time, he began to sweat profusely and to complain of a sque zing reHostcmal pain. The cath tel' tip was rcadvan 'cd into the right coronary artery orifice and another injection revealed a very severely narrowed segmcl1I in the proximal portion of its main trunk (Fig 2B). Following this, cardiac standstill oc 'ulTC'd lasting for about ten seconds. Cardiac activity re tarted immediately aft I' a couplc of blows on the precordium. Nitroglycerin was riven and anOther injection made three minutes later showpd the narrowing to persist, but to a lesscl' dcgl·cc. A final injection made five minutes aft I' nin'oglycerin revealed the unal disappearance of the arterial narrowing (Fig 2C). DISCUSSION

Coronary arterial spasm occurred quite infrequently (in less than 1 per cent of the cases) d uri n g coronary cinearteriography. The fact remains, however, that it does happen and that photographic demonstration of its development and of its relief by nitrites is now possible. Coronary arterial spasm has been seen in individuals with an apparcntly normal coronary lumen as well as in patients with coronary atherosclerosis. With the advent of coronary cinearteriography, it is much easier to demonstrate the existence of coronary spasm than to implicate its responsibility in the development of an anginal crisis.

71 7

The absence of anginal symptoms in four of se\"en pat i e n t s with coronary arterial spasm i no 'upport for those who believe that it plays an important role in their de\"clopment. On the other hand, the three other case reported above in more detail ha\"c convinced the authors of this paper that in a few indi\ iduals, coronary arterial spasm doe play an important role in the precipitation of the anginal paroxysm. There i little doubt that the spasm of the anterior descending branch of the left coronary artery occurring during coronary cinearteriography in case 3 was provoked by the rather brutal entrance of the tip of thc catheter into this vessel. The severity of the pain might also be explained in the . arne way. However, thi patient uffered many imilar episodes over a period of 18 months during which he had been submitted to marked emotional stress. The lack of ob tructive or even subobstructive coronary artery disease leads us to consider coronary arterial spasm as an important factor in the genesis of his anginal attacks. In the fourth case, the attacks which re. ulted in ho pitalization one year earlier and that which occurred immediately before coronary cinearteriography seem to be quite similar: the symptoms were identical

FIG. 2A FIG. 2B 2A (Case 4): Right coronary artery photographed in left anterior oblique projection five m.inutes after surgical sublingual administration of nitroglycerin. FIGURE 2B (Case. 4); !--ater f rIa m e taken during the same injection; note smooth lumen of the large main trunk and of Its mam branc les.

FIGURE

or

Di,eJ,e, the Che,:

DEMANY, TAMBE A:-ID ZIMMERMAN

and, although electrical evidence of myocardial injury was obtained both times, a diagnosis of myocardial infarction could

FIe URE 3A (u pper C tcry p IlOtographed ' leftase 7)·'. R'19h t corona antenor bl' ry ar· a t th every 1Jeglnning of the 0 Ique projection of the main trunk and of it procedure, The lum very smooth, FICURE 3B ( s large branChes app en f center C 7) ears s.gment? ~he Same arter ,ase : Proximal sa'!le projectIOn but magnilc!~ot~g~aphcd in the InjectIOn made two mi/lute I Y sing zoom lens . , h 'IS severe' narrowing Involving a sho Sater t ' Tere d'lately after the I' segment ' t rU,n k ,mme t k ff 0 f t h e main atfIal branch, Cardiac standstili e-o of the right about 30 sec0':lds later, Patient was resuscft~ct~de~ cardIac massage, Cardiac sta It'll 1 Y external nc S I asts bet \\·e('n ' J0 aneI I:> seconds, FIG URE 3C (I Case 7), Same artery and techniques as in FiOwer 313 l ' " !llade three minutes after sublinguaY nit~o~;~~tl?n Th,e sc\'('re narrowing has disappeared and the fIn, tcnal lull1cn appcars smooth, arD

not be substantiated. The manife tation' wcre more s '\'crc than those of an ordinary attack of angina pectoris' thi was confirmcd by the appearance of the acute injury pattern on the electrocardiogram. The rapid and complete relief of the e symptoms and the prompt disappearance of the injury current followinO' admini tration of a single nitroglycerin tablet trongl)' militate against a diagnosis of myocardial infarction. Th coronary cin arteriogram revealing the snlooth IUlllcn of the right coronary artery i.. also against it, as well as the persistently normal le\'els of "crum glutamic oxaloacctic transamina 'e and lactic dehydroO'cnase during thc following days, Thus while the actual cineanO'iographic demonstration of spa'lll i.. lacking in this casc, thc rapid tcrmination of the attack and disappearance of the injury current following nitrogl~'cerin and the coronary cinearteriogram obtained shortly after suggcst very strongl~' that spasm of the daht r.oronary arter~' \Va:' the factor respon ible for this dnunatic cri, i . The, cventh patient offers an opportunity for an interesting electrocardiographic COI'relation, The in\'crteu T wa\'e noted in leads 2, 3 and .'\ \ F on onc occasion is compatible with ischcmia of the posteroinferior wall. In the present case, a large portion of this wall was irrigated by the right coronary artery in which spasm wa later demonstrated, E\'en more interesting is the occurrence of \Venckebach phenomenon' in thi patient durinO' another attack. The examination of the arteriograms allows a tentative explanation of this electrocardiographic abnormalit\'; thc branch to the sino-atrial node an~l the one iITiO'atinO' the atrio\'entricllbr node both orio~nate from thc riO'ht D coronar~' artcr~' in this patient; hO\ve\'er, while the sino-,ltrial node branch has its origin proximal to the segment of the main trunk narrowed b~' sp;\sm, the branch to the atr;O\' 'Iltricul;lr nodc ma\' find it impos. iblc to bring enough blood' to that node be ;lUSC of a sllfTi('icntl~' :,C\'('IT spastic narrowin~' in\'ol\'ing ,I portion of the rio'ht ,~

.~

Volume H. No.6 June, 1968

CORONARY ARTERIAL SPASM

coronary artery main trunk. The sub equent ischemia of the atrioventricular node may have resulted in the prolan ation of both the effecti\'e and relative l' fractory periods and in the appearance of a second degree A-V block on the electrocardiogram. The authors believe that in a ~mall number of individuals, coronary pasm an b' held responsible for the OCcurrence of angina pectoris. The danger of :udden death from ventricular fibrillation or cardiac standstill being an intrinsic lment of the anginal syndrome, it is possihle for coronary spasm to lead to a sudden fatal outcome. This explanation se'ms particularly fitting in the case of persons suddenly dying following a. severe fright. The last patient of this series would in all probability have oeen killed b\' fear and the accompanvinlY coronary spasm if cardiac mao sage had not succeeded to restore his heart. In a rec n t cardiology textbook,S it is stated that myocardial i. chemia and coronary pain do not follow the occurrence of spasm in a normal coronary artery because the blood flow distal to the narrowing is still adequate. On the other hand, a spC\l'tic narrowing superimposed on an athero. lerotic lesion will reduce the blood flow distally and lead to the appearance of myocardial ischemia and pain. This statement is probably true as long ,l<; the spastic narrowing is only of a mild or even of a moderate degree. The last case described here, however, proves that spasm alone, if sufficiently severe, can reduce the blood flow distally and produce an attack of angina pectoris which can terminate tragically. The importance of emotional states as a •

TAIlLE

1-750

I

CORO~ARY

'"

C1NEANGIOGRA~IS

Diagnosis Arteriosclerotic heart disease Rheumatic heart disease and arteriosclerotic h art disease Rheumatic heart disease Congenital heart disease Primary myocardial disease WollT-ParkinsoJl-Whitc syndrome . Icurornllst"1I1ar chest pain Total

No. Cases

305 39 216

32 23

5

130 750

pI' clpltating factor for angina pectoris has been acknowledged for a long time. Vigorou. di ussion, heat d arguments or se,'ere frilYht ma\' all induce attacks.' Like oth I' factor pt:ecipitatin
720

coronary blood flow to only a relatively moderate extent would be another explanation for their lack of pain. When a considerable reduction in coronary blood flow takes place because of a sudden, severe, luminal narrowing, an anginal paroxysm will occur even in the presence of an otherwise normal coronary arterial tree (i.e. free of atherosclerotic deposits). lO Prinzmetal et al have described a "variant" form of angina pectoris. In this type of angina, the pain comes on with the subject at rest or during ordinary activity durmg the day or night. It is not brought on by effort. During an attack, the ST segment') are transiently and often remarkably eleva.ted ~nd there are reciprocal ST depressIOns m the standard leads'. Ad mInIS. . . tration of nitroglycerin terminates the pain and th: ~Ssociated electrocardiographic abn.ormahtles. Complete A-V bl k b oc was 0 . on t k' serve d d UrIng . d' e a tac In one case. ExerCIse Id not p d ST N . ro uce segment elevation. ecropsles of several of their patients reof severe disease (+80 vealed the prese~ce per cent narrowmg) in at least . coronary artery. one major Although its exi tioned 11 othe 12.14 ~tence ha been quescases ~h' h rs ave reported similar expl'ain :~is spe:mrawdell. documented. To . ' et LIO OXiC form 0 f angma, . P nnzmetal sient . . a postulated that a tran, mcrcase In arterial t < one could lead to complete bu t t narrOwed m' emporary obstruction of a aJor vessel, thus producing pain and ST elev~tion. They thought that arte;~:f%:n: was mcreased at rest and TABLE

Case

Sex

2

M M

3

4 5 6

7

oi the Chest

Di~lSes

DEMANY} TAMBE AND ZIMMERMAN

M M M

M M

A 53ge 37

55

43 47 49

32

Vessel Involved RCA LCA Ant. D. RCA RCA RCA RCA

Catheter Induced *

* X

decreased on exercise. The three patients reported above in detail (case. 3, 4 and 7) ha\'e some feature' in common with those reported by Prinzmetal et al'o: attack of pain occurring at re:t (cases 3, 4, 7), T seoment elevation (case 4), !\- V block (second degree, ~~ e 7), relief following nitroulycerin adminiStration (cases 3, 4, 7) and lack of ST egment el~vation durinu exercise test (case 4, 7). The big difference, however, lies }n the ahsence of demonstrable coronary dISease in the large arterial trunks of our patients. If one believes in the valiant form of angina, then one can say that coronary c spasm alone can produce it. SUMMARY

In a series of 750 coronary cinearteriograms, coronary spasm was observed in only seven individuals. At the time of the cinearteriogram, three experienced an attack of chest pain that had all the feature of coronarv insufficiency before the spasm was relieved b) nitroglycerin. One of these three patients displayed an acute dial injury pattern on the electrocardIOgram, another one went into cardiac standstill which responded to external massage. Coronary spa'm is probably due to the action of catecholamine on the alpha receptors of the large coronary vessels, whereas myocardial anoxia can still be considered the immediate cause of the cardiac pain. Differences in the symptomatic manifestations occurring during coronary spasm may be due to the '-degree of arterial narrowing, 2

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*:j: II Abbreviations: RCA Ri ht . .artery;. LCA=Left coronary artery; Ant. Desc.=Antenor ing branch of left coron;r coron~ry rotic heart disease' LV D ! Lartery, qlrc.=Clrcun:Aex branch of left coronary artery; ASHD=Artenosc!e*-M'ld I um1l1a . I narrow1I1g ' . ,- less eft tlla ventncular end diastolic !)ressure. . Severity of ASHD or of .coronary spasm: I 20 . h ?O d , n per cent caltbcr reducuon' t=Moderalc narrowlI1g, more I an - all less than 7;) per cent caliber reduction; :j:-Marked narrowi,;g, over 75 per cent caliber reduction.

Volume H. No.6 June. 1968

CORO)
to the presence or absence of coronary artery disease and also to individual differences in pain thre hold. Whatever its final mechanism coronary ~pasm may, in an occasional individual 1 e responsible for an attack of angina pectoris and even for sudden death. RESUMloN En el curso de 750 cineancriografias S' observo el espasmo coronado en solo siele sujetGs. En el momenlO del arteriograma corona rio tn's de ellos experimenraron dolor toracico con todas Jas caracterlsticas de la insullciencia corona ria. hasta que el espasmo fu' suprimido pOl' la nit1·o~ glicerina. Uno d estos Ires paciemes exhibi6 caml:Jios electrocardiogrMi os rcveladorcs de lesion aguda del miocardio, en 011'0 sobr vino I paro cardiaco, que r 'spondi6 al masaje externo del corazan. EI espasmo corona rio cs prohablcm'me d bido a la aceion de la caleculamina sabre los receplares a\fa de los va 'Os coronarios maym'e , mientras que la anoxia del miocardia puedc aun er considerada como la au a inmecliala del dolor cardiaco. Las cliferencias n las manife lacion . en el curso del c'paSlllO corona rio puecl n'er arril:Juidas al grado d· slr'chami nlo vascular a a la presencia 0 auspncia de enfcrmedad arlerial coronaria y tambien a variacion s individuales en el umbral de per epci6n d I dolor. Cualqui ra quc sea su mecanismo ullimo, el espasmo arterial coronariu pueclc, en algun que 011'0 individuo, scI' 101 causa cle un ataque de pecho y aun d mucn sllhita. ZUSAM MENFi\SSU NG In cineI' Serie von 750 Coronar-Cine-Artcriogrammen wurde ein Coronarspa mus bei nul' sieben Personen bcobachlet. Zur Zeit des Cinearteriogram illS erliltcn dl-ci von ihnen cine Brustschmcrzanacke, die all, Zcichcn von Curonarinsuffizienz aufwies, be\'ur del' Spaslllus durch ~ilroglycerin behoben wmde. Einer von diescn drei Patienten elllwickelte einc akut Myokardschadenkurve auf clem Elektrokardiogramm, ein anderer bekam cinen Herzstillslancl, del' auf au~ere Herzmassage ansprach. Coronarspa mus wird wahrschcinlich c1urch die Wirkung von Katccholamin auf die Alpha-R zep.

tor n del' gro~en Coronarge£li13e bedingt, wlihrend ivI\'okal'danoxie immer noch al del' unmittelbare GI:und fiir den HCI-t:schmcrz angesehen werden ka1111. Un I ere hie d e in d n ymptomatischen Ersclwinung n. die wlihrend eines CoronarspasInUS uuftreten, konnen durch den Grad del' Artcrienverungung, das \ orhandensein odeI' Nicht\'0 l' han den se i n cineI' Coronararterienkrankheit, unci auch durch individuelle Unterschiede in del' S 'hmcl'7.schwelle heeling! sein. Unabhangig von seinem lelztlichen Mechanismus kann ein Coronarspastnlls gelegemlich del' Grund flir einen Angina pectoris-Anfall und sogar fUr plotzlichen Tod sein. REFERENCES LATHAM, P. ?vI.: Collected works, New Sydellham Soc. London, 1876, Vol. 1, quoted by Friedberg, C. K.: Diseases of the heart, W. B. Saunders Co., Philadelphia (3rd Ed.), 1966. 2 GALLAVARDIN, L.: Lyon Med., 151:217, 1933, quoted by Friedberg, C. K. as abo~e. . 3 HILAL, H. AND MASSUMI, R.: Vanant angma pectoris, Am. ]. Cardiology, 19:607, 1967: 4 SOl'ES, F. M., JR. AND SHIREY, E. K.: Cmecoronary arteriography, Modem Concepts Cardiovas. Dis., 31 :735, 1962. . 5 WENCKEBACH, K. F.: Die unregelmasSig e Herztatigkeit und ihr~ klinisch.e Bedeutung, 'A'. Englemann, LeipZig and Berlin, 1914... 6 LOCUE, R. B. AND HURST, W. T.:. Clldlci~; recognition of coronary atherosclerOSIS an H'Il complications in the heart, Ed. McGraw- I , ew York, 1966. 7 FRIEDBERC, C. K.: Diseases of the heart, W. B. Saunders Co., Philadelphia (3rd Ed.), 19 66 8 YURCHAK, P. ?vL, ROLETT, E. C., COHEN! L . S. AND GORLlN, R.: Effect of norephinephnne. on the coronary circulation in man, ClrcltlatlOll, 30:180,196'k d'sand 9 MORAN, N. C.: Adrenergic receptors, lU g ts the cardiovascular system, Modern COl1ceP Cardiouas. Dis., 35: 99, 1966. R, 10 PRINZM£TAL, M., KENNAMER, R., MERLIS~, i WADA, T. AND BO.R, N.: Ang!na pectons. d' A variant form of angina pectons, Am. j. Me ., 27:375, 1959. 11 FRIEDBERG C. K.: Diseases of the heart, W. B. Saunders 'Philadelphia, 1966. . 12 GUDBAY, E. R.: Prinzmetal's variant angma, Canad. M. A. }., 83: 164, 1960. . 13 PER£TZ, D. 1.: Variant angina pectoris of Pnnz· metal, Callad. M. A. }., 85: 1101 1961. . 14 RODIN SON, J. S.: Prinzmetal's variant ang70~ pectoris. Report of a case, Am. Heart j., . 797, 1965. For reprints, please write: Dr. Zimmerman, 250 Hanna Building, Cleveland 41115.