Abstract
Background
Up to 30% of patients with acute coronary syndrome have no culprit lesion. Coronary microvascular spasm is an alternative cause for such a clinical presentation. However, this has rarely been investigated systematically. The aim of our study was to assess the frequency of coronary microvascular spasm in patients with NSTEMI without culprit lesion (MINOCA) by intracoronary acetylcholine testing (ACH-test).
Methods
Between 2014 and 2017, 940 patients with NSTEMI underwent coronary angiography and 125 (13%) had no culprit lesion (< 50% stenosis on visual assessment). Of the latter, 29 patients had other causes for the clinical presentation (e.g. tako-tsubo-syndrome or myocarditis). The remaining 96 patients were recruited for the study and underwent ACH-testing according to a standardized protocol.
Results
The ACH-test was normal in 40 (42%) and abnormal in the remaining 56 (58%) patients. Of the latter, 26 patients (46%) had epicardial spasm (epicardial narrowing ≥ 90%, reproduction of symptoms and ischemic ST-segment changes) and 30 (54%) microvascular spasm (ischemic ST-shifts and angina without epicardial vasoconstriction ≥ 90%). The peak high-sensitive troponin-T concentration was 113 (42–255) pg/ml. Patients with coronary spasm had more often a positive family history compared to those without and patients with epicardial compared to microvascular spasm were more often smokers.
Conclusion
Coronary microvascular spasm is frequently found in patients with NSTEMI without culprit lesion and represents a likely cause of myocardial injury. ACH-testing is useful for detection of vasomotor disorders allowing tailored treatment with calcium antagonists and/or nitrates in addition to secondary prevention to improve symptoms and prognosis.
Graphic abstract
Microvascular spasm in non-ST-segment elevation myocardial infarction without culprit lesion (MINOCA)
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Abbreviations
- ACS:
-
Acute coronary syndrome
- AHA:
-
American heart association
- NSTEMI:
-
Non-ST-elevation myocardial infarction
- URL:
-
Upper reference limit
- GFR:
-
Glomerular filtration rate
- TTS:
-
Tako-tsubo-syndrome
- ACH:
-
Acetylcholine
- LCA:
-
Left coronary artery
- RCA:
-
Right coronary artery
- ECG:
-
Electrocardiogram
- MRI:
-
Magnetic resonance imaging
- MINOCA:
-
Myocardial infarction with nonobstructed coronary arteries
- MI:
-
Myocardial infarction
- PCI:
-
Percutaneous coronary intervention
- TIA:
-
Transient ischemic attack
- LVEF:
-
Left ventricular ejection fraction
- NOAC:
-
Novel oral anticoagulant
- ACE:
-
Angiotensin-converting-enzyme
- CCB:
-
Calcium channel blocker
- SVT:
-
Supraventricular tachycardia
- AS:
-
Aortic stenosis
- HNCM:
-
Non-obstructive hypertrophic cardiomyopathy
References
Hochman JS, Tamis JE, Thompson TD et al (1999) Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIb investigators. N Engl J Med 341:226–232
Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD (2019) ESC scientific document group. Fourth universal definition of myocardial infarction (2018). Eur Heart J 40:237–269
Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, De Caterina R, Zimarino M, Roffi M, Kjeldsen K, Atar D, Kaski JC, Sechtem U, Tornvall P (2017) WG on cardiovascular pharmacotherapy. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J 38:143–153
Vargas KG, Haller PM, Jäger B, Tscharre M, Binder RK, Mueller C, Lindahl B, Huber K (2018) Variations on classification of main types of myocardial infarction: a systematic review and outcome meta-analysis. Clin Res Cardiol. https://doi.org/10.1007/s00392-018-1403-3[Epub ahead of print]
Sandoval Y, Thordsen SE, Smith SW, Schulz KM, Murakami MM, Pearce LA, Apple FS (2014) Cardiac troponin changes to distinguish type 1 and type 2 myocardial infarction and 180-day mortality risk. Eur Heart J Acute Cardiovasc Care 3:317–325
Ong P, Athanasiadis A, Hill S, Vogelsberg H, Voehringer M, Sechtem U (2008) Coronary artery spasm as a frequent cause of acute coronary syndrome: the CASPAR (coronary artery spasm in patients with acute coronary syndrome) study. J Am Coll Cardiol 52:523–527
Wang CH, Kuo LT, Hung MJ et al (2002) Coronary vasospasm as a possible cause of elevated cardiac troponin I in patients with acute coronary syndrome and insignificant coronary artery disease. Am Heart J 144:275–281
Nakayama N, Kaikita K, Fukunaga T, Matsuzawa Y, Sato K, Horio E, Yoshimura H, Mizobe M, Takashio S, Tsujita K, Kojima S, Tayama S, Hokimoto S, Sakamoto T, Nakao K, Sugiyama S, Kimura K, Ogawa H (2014) Clinical features and prognosis of patients with coronary spasm-induced non-ST-segment elevation acute coronary syndrome. J Am Heart Assoc 3:e000795
Yu M, Zhang Q, Huang X (2018) Acute coronary syndrome due to right coronary spasm and documented lambda-like J waves. Clin Res Cardiol 107:729–732
Montone RA, Niccoli G, Fracassi F, Russo M, Gurgoglione F, Cammà G, Lanza GA, Crea F (2018) Patients with acute myocardial infarction and non-obstructive coronary arteries: safety and prognostic relevance of invasive coronary provocative tests. Eur Heart J 39:91–98
Grodzinsky A, Arnold SV, Gosch K, Spertus JA, Foody JM, Beltrame J, Maddox TM, Parashar S, Kosiborod M (2015) Angina frequency after acute myocardial infarction in patients without obstructive coronary artery disease. Eur Heart J Qual Care Clin Outcomes 1:92–99
Task Force Members, Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Taggart DP, van der Wall EE, Vrints CJ, ESC Committee for Practice Guidelines, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Document Reviewers, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, Gonzalez-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Kristensen SD, Lancellotti P, Maggioni AP, Piepoli MF, Pries AR, Romeo F, Rydén L, Simoons ML, Sirnes PA, Steg PG, Timmis A, Wijns W, Windecker S, Yildirir A, Zamorano JL (2013) ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European society of cardiology. Eur Heart J 2013(34):2949–3003
Yilmaz A, Mahrholdt H, Athanasiadis A, Vogelsberg H, Meinhardt G, Voehringer M, Kispert EM, Deluigi C, Baccouche H, Spodarev E, Klingel K, Kandolf R, Sechtem U (2008) Coronary vasospasm as the underlying cause for chest pain in patients with PVB19 myocarditis. Heart 94:1456–1463
Sueda S, Kohno H, Ochi T, Uraoka T, Tsunemitsu K (2017) Overview of the pharmacological spasm provocation test: comparisons between acetylcholine and ergonovine. J Cardiol 69:57–65
Gross L, Epstein EZ, Kugel MA (1934) Histology of the coronary arteries and their branches in the human heart. Am J Pathol 10(253–274):7
Thorin E (2001) Influence of nitric oxide synthase inhibition and endothelin-1 receptor blockade on acetylcholine-induced coronary artery contraction in vitro in dilated and ischemic cardiomyopathies. J Cardiovasc Pharmacol 38:90–98
Pelliccia F, Kaski JC, Crea F, Camici PG (2017) Pathophysiology of takotsubo syndrome. Circulation 135:2426–2441
Gassanov N, Le MT, Caglayan E, Hellmich M, Erdmann E, Er F (2019) Novel ECG-based scoring tool for prediction of takotsubo syndrome. Clin Res Cardiol 108:68–73
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This work was done with support from the Robert-Bosch-Foundation (KKF 770) and the Berthold-Leibinger-Foundation.
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This work was done with support from the Robert-Bosch-Foundation (KKF 770) and the Berthold-Leibinger-Foundation.
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Pirozzolo, G., Seitz, A., Athanasiadis, A. et al. Microvascular spasm in non-ST-segment elevation myocardial infarction without culprit lesion (MINOCA). Clin Res Cardiol 109, 246–254 (2020). https://doi.org/10.1007/s00392-019-01507-w
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DOI: https://doi.org/10.1007/s00392-019-01507-w