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Refractory ergonovine induced coronary vasospasm: importance of intracoronary nitroglycerin
ABSTRACTS
EFFICACY OF NIFEDIPINE IN THE INTERMEDIATE SYNDROME REFRACTORY TO PROPRANOLOL AND NITRATE THERAPY Jeffrey Moses, MD; Michael S. Feldman, MD, FACC; Richard H. Helfant, MD, FACC, Presbyterian-University of Pennsylvania Medical Center, Philadelphia, Pennsylvania. The intermediate syndrome (recurrent angina at rest with ST segment and/or T wave changes without serum enzyme elevations) is often refractory to conventional medical The utility of nifedipine was evaluated in 13 therapy. patients with obstructive coronary disease (3 with 3 vessel disease (VD), 5 with 2 VD, 4 with 1 VD and 1 with acute inferior myocardial infarction) and the intermediSeven had continued rest pain 3 days to ate syndrome. One had 6 weeks after an acute myocerdial infarction. variant angina. All were refractory to propranolol (go-320 mg/day) oral nitrates (isosorbide 240-320 n&day) and nitroglycerin ointment (4-12 inches/day) to tolerance The addition of nifedipine in oral doses of 30-120 mg daily abolished rest pain in 11 patients. Two patients considered non-responsive (1 - ZVD, 1 - 3VD) underwent After initial titration with nifedipine, bypass surgery. 5 patients were NYHA class I, 7 class II and 1 class IV. After 3 weeks to 6 months followup, 8 patients remained on nifedipine. One patient with 3 VD had recurrent rest pain at 5 weeks and had bypass surgery. One patient stopped nifedipine due to diarrhea and 1 was lost to followup. Of those who continued nifedipine 5 remained NYHA class I and 3 class II. Three of 4 patients who had reduced the dose of nifedipine had recurrent rest pain. Side effects were: 1 patient with congestive failure, 1 with diarrhea and 1 with ankle edema. Thus, nifedipine is a potentially useful drug in patients with the intermediate syndrome and may help defer or avoid the need for coronary bypass surgery.
REFRACTORY ERGONOVINE INDUCED CORONARY VASOSPASM: IMPORTANCE OF INTRACORONARY NITROGLYCERIN Alfred Buxton, MD; Sheldon Goldberg, MD; John W. Hirshfeld, MD; John Wilson, MD; Tift Mann, MD; David 0. Williams, MD; Philip Oliva, MD, FACC; John A. Kastor, MD, FACC, Hospital of the University of Pennsylvania, Philadelphia, PA Recent experience has suggested that the ergonovine maleate test is a safe procedure for the diagnosis of variant angina pectoris, since ergonovine-induced COT"nary vasospasm has generally been reversible by sublingual nitroglycerin. 0 e report 4 cases of ergonovineinduced coronary vasospasm which were refractory to sublingual nitroglycerin and resulted in cardiac arrest. In one patient the vasospasm was responsive only to intracoronary nitroglycerin administration. Three patients died as a result of intractable coronary vaso*pasIll. The one survivor differed from the nonsurvivors in the total dose of ergonovine (O.lmg versus 0.15, 0.3, and 0.3mg respectively), and in the method of administration of ergonovine. The survivor was given serial doses of 0.05 each whereas the three nonsurvivors received either larger initial doses (O.lmg followed by 0.07mg) or progressive incremental doses (O.O5mg, O.lmg, and 0.15mg serially). Sublingual nitroglycerin, given to all 4 patients and intravenous nitroglycerin, given to 3 of the 4 were ineffective in reversing vasospasm. Multiple doses of intracoronary nitroglycerin reversed coronary vasospasm in the survivor. Thus, the ergonovine maleate test is not benign and may cause severe coronary vasospasm that is unresponsive to sublingual and intravenous nitroglycerin, but may be reversed by intracoronary nitroglycerin.
390
February 1980
The American Journal of CARDIOLOGY
FIXED VS. NON-FIXED CORONARY STENOSIS: THE RESPONSE TO A FALL IN CORONARY PRESSURE. Jeffrey S Schwartz, MD, Peter Carlyle, BS, Jay N Cohn MD, FACC; University of Minnesota, Minneapolis, Minnesota. The resistance of a coronary stenosis capable of passive vasomotion may change in response to alterations in transmural pressure. We studied the effects of a fall in perfusion pressure on the hemodynamics of 3 types of coronary stenosis in 17 open chest dogs: 1) a noncircumferential stenosis (NCS) produced by placing sutures into either side of the artery and invaginating part of the arterial wall by tying the sutures, 2) a stenosis produced by placing a soft wire snare (WS) around the artery, and 3) a fixed circumferential stenosis (CS) produced by introducing and tying a short section of hollow plastic tubing into the coronary artery. Aortic pressure, coronary pressure proximal and distal to the stenosis and coronary flow were measured. Pressure in the stenotic artery was lowered by tightening a snare placed very In arteries with a NCS, proximally on the artery. lowering proximal coronary artery pressure (PCP) by 52+5 mmHg caused a rise in stenosis resistance from 0.43+O.isj to 1.10+0.25 units (p
FREQUENCY OF PROVOCATED CORONARY ARTERY SPASM IN 273 PATIENTS WITH CHEST PAIN M.Labla"che,MD; Michel E. Bertrand,MD,FACC;Jean Pierre Y.Tilmant,MD:Univer*ity Hospital,Division of Cardiology,Hopital Cardiologique,Lille,France Provocative test with metherginewas systematically performedina group of 273 patientscpts) referred by coronary arteriography for evaluation ofchest pain.The provocative test was performed after the routine procedure using a protocolwith a single IV bolus injection of 0.4 mg of metherg ine.Aortic pressure,ECG and coronary arteriogram were repeated 1,3 and 5 minutes later.The pts were divided into 4 groups:Group l(n=94):Atypical chest pain.G+oup Z(n=39):Typical angina pain during exercise 5(15 pts had previous myocardial infarction)Group 3(1?=98):Typical angina pain at rest.Group 3(n=42):Both angina at rest and during exercise.32 pts in group 3 and 5 in group 4 had ST segment elevation during the attacks. n SpaSIll NO spasm Group 1 94 0 94 Group 2 39 1 38 45 53 Group 3 98 Group 4 42 7 35 Total 273 53 220 Coronary ;pasm(CS) was observed in 19.4% of pts. Spasm was seldom observed in pts with atypical chest pain or angina on exertion.In contrast spasm is frequently induced I" pts with angina at rest (group 2+3):52/140=37%.35 of 37 pts with ST segment elevation had coronary spasm.1" conclusion:It appears that chest pain 1s related to spasm in approximatively 20% of pts and mostoften in pts with spontaneous angina at'rest:In this the best indication for way I these pts represent the provocative test.
Volume 45
EFFICACY OF NIFEDIPINE IN THE INTERMEDIATE SYNDROME REFRACTORY TO PROPRANOLOL AND NITRATE THERAPY Jeffrey Moses, MD; Michael S. Feldman, MD, FACC; Richard H. Helfant, MD, FACC, Presbyterian-University of Pennsylvania Medical Center, Philadelphia, Pennsylvania. The intermediate syndrome (recurrent angina at rest with ST segment and/or T wave changes without serum enzyme elevations) is often refractory to conventional medical The utility of nifedipine was evaluated in 13 therapy. patients with obstructive coronary disease (3 with 3 vessel disease (VD), 5 with 2 VD, 4 with 1 VD and 1 with acute inferior myocardial infarction) and the intermediSeven had continued rest pain 3 days to ate syndrome. One had 6 weeks after an acute myocerdial infarction. variant angina. All were refractory to propranolol (go-320 mg/day) oral nitrates (isosorbide 240-320 n&day) and nitroglycerin ointment (4-12 inches/day) to tolerance The addition of nifedipine in oral doses of 30-120 mg daily abolished rest pain in 11 patients. Two patients considered non-responsive (1 - ZVD, 1 - 3VD) underwent After initial titration with nifedipine, bypass surgery. 5 patients were NYHA class I, 7 class II and 1 class IV. After 3 weeks to 6 months followup, 8 patients remained on nifedipine. One patient with 3 VD had recurrent rest pain at 5 weeks and had bypass surgery. One patient stopped nifedipine due to diarrhea and 1 was lost to followup. Of those who continued nifedipine 5 remained NYHA class I and 3 class II. Three of 4 patients who had reduced the dose of nifedipine had recurrent rest pain. Side effects were: 1 patient with congestive failure, 1 with diarrhea and 1 with ankle edema. Thus, nifedipine is a potentially useful drug in patients with the intermediate syndrome and may help defer or avoid the need for coronary bypass surgery.
REFRACTORY ERGONOVINE INDUCED CORONARY VASOSPASM: IMPORTANCE OF INTRACORONARY NITROGLYCERIN Alfred Buxton, MD; Sheldon Goldberg, MD; John W. Hirshfeld, MD; John Wilson, MD; Tift Mann, MD; David 0. Williams, MD; Philip Oliva, MD, FACC; John A. Kastor, MD, FACC, Hospital of the University of Pennsylvania, Philadelphia, PA Recent experience has suggested that the ergonovine maleate test is a safe procedure for the diagnosis of variant angina pectoris, since ergonovine-induced COT"nary vasospasm has generally been reversible by sublingual nitroglycerin. 0 e report 4 cases of ergonovineinduced coronary vasospasm which were refractory to sublingual nitroglycerin and resulted in cardiac arrest. In one patient the vasospasm was responsive only to intracoronary nitroglycerin administration. Three patients died as a result of intractable coronary vaso*pasIll. The one survivor differed from the nonsurvivors in the total dose of ergonovine (O.lmg versus 0.15, 0.3, and 0.3mg respectively), and in the method of administration of ergonovine. The survivor was given serial doses of 0.05 each whereas the three nonsurvivors received either larger initial doses (O.lmg followed by 0.07mg) or progressive incremental doses (O.O5mg, O.lmg, and 0.15mg serially). Sublingual nitroglycerin, given to all 4 patients and intravenous nitroglycerin, given to 3 of the 4 were ineffective in reversing vasospasm. Multiple doses of intracoronary nitroglycerin reversed coronary vasospasm in the survivor. Thus, the ergonovine maleate test is not benign and may cause severe coronary vasospasm that is unresponsive to sublingual and intravenous nitroglycerin, but may be reversed by intracoronary nitroglycerin.
390
February 1980
The American Journal of CARDIOLOGY
FIXED VS. NON-FIXED CORONARY STENOSIS: THE RESPONSE TO A FALL IN CORONARY PRESSURE. Jeffrey S Schwartz, MD, Peter Carlyle, BS, Jay N Cohn MD, FACC; University of Minnesota, Minneapolis, Minnesota. The resistance of a coronary stenosis capable of passive vasomotion may change in response to alterations in transmural pressure. We studied the effects of a fall in perfusion pressure on the hemodynamics of 3 types of coronary stenosis in 17 open chest dogs: 1) a noncircumferential stenosis (NCS) produced by placing sutures into either side of the artery and invaginating part of the arterial wall by tying the sutures, 2) a stenosis produced by placing a soft wire snare (WS) around the artery, and 3) a fixed circumferential stenosis (CS) produced by introducing and tying a short section of hollow plastic tubing into the coronary artery. Aortic pressure, coronary pressure proximal and distal to the stenosis and coronary flow were measured. Pressure in the stenotic artery was lowered by tightening a snare placed very In arteries with a NCS, proximally on the artery. lowering proximal coronary artery pressure (PCP) by 52+5 mmHg caused a rise in stenosis resistance from 0.43+O.isj to 1.10+0.25 units (p
FREQUENCY OF PROVOCATED CORONARY ARTERY SPASM IN 273 PATIENTS WITH CHEST PAIN M.Labla"che,MD; Michel E. Bertrand,MD,FACC;Jean Pierre Y.Tilmant,MD:Univer*ity Hospital,Division of Cardiology,Hopital Cardiologique,Lille,France Provocative test with metherginewas systematically performedina group of 273 patientscpts) referred by coronary arteriography for evaluation ofchest pain.The provocative test was performed after the routine procedure using a protocolwith a single IV bolus injection of 0.4 mg of metherg ine.Aortic pressure,ECG and coronary arteriogram were repeated 1,3 and 5 minutes later.The pts were divided into 4 groups:Group l(n=94):Atypical chest pain.G+oup Z(n=39):Typical angina pain during exercise 5(15 pts had previous myocardial infarction)Group 3(1?=98):Typical angina pain at rest.Group 3(n=42):Both angina at rest and during exercise.32 pts in group 3 and 5 in group 4 had ST segment elevation during the attacks. n SpaSIll NO spasm Group 1 94 0 94 Group 2 39 1 38 45 53 Group 3 98 Group 4 42 7 35 Total 273 53 220 Coronary ;pasm(CS) was observed in 19.4% of pts. Spasm was seldom observed in pts with atypical chest pain or angina on exertion.In contrast spasm is frequently induced I" pts with angina at rest (group 2+3):52/140=37%.35 of 37 pts with ST segment elevation had coronary spasm.1" conclusion:It appears that chest pain 1s related to spasm in approximatively 20% of pts and mostoften in pts with spontaneous angina at'rest:In this the best indication for way I these pts represent the provocative test.
Volume 45