Ergonovine Stress Echocardiography for the Diagnosis of Vasospastic Angina

  • Jae-Kwan Song
  • Eugenio Picano

Coronary artery spasm has been considered one of the major mechanisms causing dynamic stenosis of epicardial coronary arteries, which can evoke acute myocardial ischemia. Vasospastic angina caused by coronary artery spasm has a wide clinical spectrum: one of its typical clinical manifestations is variant angina. Coronary vasospasm has also been documented to contribute to the development of unstable angina or acute myocardial infarction [1]. Classically, coronary artery spasm is diagnosed by an invasive provocative procedure during diagnostic coronary angiography. Since various noninvasive diagnostic tests for fixed atherosclerotic stenosis of epicardial coronary arteries (exercise ECG, stress echocardiography, and nuclear tests) are being used in routine daily practice, it would be useful to establish a reliable, noninvasive, and safe diagnostic method to document coronary artery spasm in the management of patients with vasospastic angina.

The rare episodic nature of coronary artery spasm makes it extremely difficult to document spontaneous coronary vasospasm in clinical practice. The noninvasive stress tests currently used are ergonovine [2], acetylcholine [3], and systemic alkalosis by hyperven-tilation [4]. Of these, spasm-provocation testing using ergonovine is considered the gold standard for diagnosis of coronary artery spasm because of its high sensitivity and specificity. Acetylcholine seems to have comparable diagnostic validity for intracoronary administration, but its short half-life for the abundant pseudocholinesterase in human plasma makes intravenous injection inadequate for spasm provocation.


Stress Echocardiography Regional Wall Motion Abnormality Coronary Artery Spasm Coronary Vasospasm Variant Angina 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Maseri A (1987) Role of coronary artery spasm in symptomatic and silent myocardial ischemia. J Am Coll Cardiol 9:249–262PubMedGoogle Scholar
  2. 2.
    Heupler FA Jr, Proudfit WL, Razavi M, et al (1978) Ergonovine maleate provocative test for coronary arterial spasm. Am J Cardiol 41:631–640PubMedCrossRefGoogle Scholar
  3. 3.
    Yasue H, Horio Y, Nakamura N, et al (1986) Induction of coronary artery spasm by acetylcho-line in patients with variant angina: possible role of the parasympathetic nervous system in the pathogenesis of coronary artery spasm. Circulation 74:955–963PubMedGoogle Scholar
  4. 4.
    Yasue H, Nagao M, Omote S, et al (1978) Coronary arterial spasm and Prinzmetal's variant form of angina induced by hyperventilation and Tris-buffer infusion. Circulation 58:56–62PubMedGoogle Scholar
  5. 5.
    Muller-Schweinitzer E (1980) The mechanism of ergometrine-induced coronary arterial spasm. In vitro studies on canine arteries. J Cardiovasc Pharmacol 2:645–655PubMedCrossRefGoogle Scholar
  6. 6.
    Mantyla R, Kanto J (1981) Clinical pharmacokinetic of methylergometrine (methylergono-vine). Int J Clin Pharmacol Biopharm 19:386–391Google Scholar
  7. 7.
    Heupler FA (1980) Provocative testing for coronary arterial spasm. Risk, method and rationale. Am J Cardiol 46:335–337PubMedCrossRefGoogle Scholar
  8. 8.
    Song JK, Park S W, Kim JJ, et al (1994) Values of intravenous ergonovine test with two-dimensional echocardiography for diagnosis of coronary artery spasm. J Am Soc Echocardiogr 7:607–615PubMedGoogle Scholar
  9. 9.
    Song JK, Lee SJK, Kang DH, et al (1996) Ergonovine echocardiography as a screening test for diagnosis of vasospastic angina before coronary angiography. J Am Coll Cardiol 27:1156–1161PubMedCrossRefGoogle Scholar
  10. 10.
    Distante A, Rovai D, Picano E, et al (1984) Transient changes in left ventricular mechanics during attacks of Prinzmetal's angina: an M-mode echocardiographic study. Am Heart J 107:465–474PubMedCrossRefGoogle Scholar
  11. 11.
    Distante A, Rovai D, Picano E, et al (1984) Transient changes in left ventricular mechanics during attacks of Prinzmetal's angina: a two-dimensional echocardiographic study. Am Heart J 108:440–446PubMedCrossRefGoogle Scholar
  12. 12.
    Distante A, Picano E, Moscarelli E, et al (1985) Echocardiographic versus hemodynamic monitoring during attacks of variant angina pectoris. Am J Cardiol 55:1319–1322PubMedCrossRefGoogle Scholar
  13. 13.
    Rovai D, Distante A, Moscarelli E, et al (1985) Transient myocardial ischemia with minimal electrocardiographic changes: an echocardiographic study in patients with Prinzmetal's angina. Am Heart J 109:78–83PubMedCrossRefGoogle Scholar
  14. 14.
    Morales MA, Lombardi M, Distante A, et al (1985) Ergonovine-echo test assess the significance of chest pain at rest without ECG changes. Eur Heart J 16:1361–1366Google Scholar
  15. 15.
    Song JK, Park S W, Kang DH, et al (1998) Diagnosis of coronary vasospasm in patients with clinical presentation of unstable angina using ergonovine echocardiography. Am J Cardiol 82:1475–1478PubMedCrossRefGoogle Scholar
  16. 16.
    Song JK, Park S W, Kang DH, et al (2000) Safety and clinical impact of ergonovine stress echocardiography for diagnosis of coronary vasospasm. J Am Coll Cardiol 35:1850–1856PubMedCrossRefGoogle Scholar
  17. 17.
    Nedeljkovic MA, Ostojic M, Beleslin B, et al (2001) Efficiency of ergonovine echocardiography in detecting angiographically assessed coronary vasospasm. Am J Cardiol 88:1183–1187PubMedCrossRefGoogle Scholar
  18. 18.
    Palinkas A, Picano E, Rodriguez O, et al (2002) Safety of ergot stress echocardiography for noninvasive detection of coronary vasospasm. Coron Artery Dis 12:649–654CrossRefGoogle Scholar
  19. 19.
    Buxton A, Goldberg S, Hirshfeld J W, et al (1980) Refractory ergonovine-induced vasospasm: importance of intracoronary nitroglycerin. Am J Cardiol 46:329–334PubMedCrossRefGoogle Scholar
  20. 20.
    Pepine CJ, Feldman RJ, Conti CR (1982) Action of intracoronary nitroglycerin in refractory coronary artery spasm. Circulation 65:411–414PubMedGoogle Scholar
  21. 21.
    Song JK, Park S W, Kang DH, et al (2002) Prognostic implication of ergonovine echocardiog-raphy in patients with near normal coronary angiogram or negative stress test for significant fixed stenosis. J Am Soc Echocardiogr 15:1346–1352PubMedCrossRefGoogle Scholar
  22. 22.
    Hamilton KK, Pepine CJ (2000) A renaissance of provocative testing for coronary spasm? J Am Coll Cardiol 35:1857–1859PubMedCrossRefGoogle Scholar
  23. 23.
    van der Burg AE, Bax JJ, Boersma E, et al (2004) Standardized screening and treatment of patients with life-threatening arrhythmias: the Leiden out-of-hospital cardiac arrest evaluation study. Heart Rhythm 1:51–57PubMedCrossRefGoogle Scholar
  24. 24.
    Epureanu V, San Román JA, Vega JL, et al (2002) Acute pulmonary edema with normal coronary arteries: mechanism identification by ergonovine stress echocardiography. Rev Esp Cardiol 55:775–777PubMedGoogle Scholar
  25. 25.
    Previtali M, Repetto A, Panigada S, et al (2008) Left ventricular apical ballooning syndrome: prevalence, clinical characteristics and pathogenetic mechanisms in a European population. Int J Cardiol May 26Google Scholar
  26. 26.
    Lombardi M, Morales MA, Michelassi C, et al (1993) Efficacy of isosorbide-5-mononitrate versus nifedipine in preventing spontaneous and ergonovine-induced myocardial ischaemia. A double-blind, placebo-controlled study. Eur Heart J 14:845–851PubMedGoogle Scholar
  27. 27.
    Barinagarrementeria F, Cantú C, Balderrama J (1992) Postpartum cerebral angiopathy with cerebral infarction due to ergonovine use. Stroke 23:1364–1366PubMedGoogle Scholar
  28. 28.
    Salem DN, Isner JM, Hopkins P, et al (1984) Ergonovine provocation in postpartum myocar-dial infarction. Angiology 35:110–114PubMedCrossRefGoogle Scholar
  29. 29.
    Nall KS, Feldman B (1998) Postpartum myocardial infarction induced by Methergine. Am J Emerg Med 16:502–504PubMedCrossRefGoogle Scholar
  30. 30.
    Yaegashi N, Miura M, Okamura K (1999) Acute myocardial infarction associated with post-partum ergot alkaloid administration. Int J Gynaecol Obstet 64:67–68PubMedCrossRefGoogle Scholar
  31. 31.
    Ribbing M, Reinecke H, Breithardt G et al (2001) Acute anterior wall infarct in a 31-year-old patient after administration of methylergometrine for peripartal vaginal hemorrhage. Herz 26:489–493PubMedGoogle Scholar
  32. 32.
    Hayashi Y, Ibe T, Kawato H, et al (2003) Postpartum acute myocardial infarction induced by ergonovine administration. Intern Med 42:983–986PubMedCrossRefGoogle Scholar
  33. 33.
    Ichiba T, Nishie H, Fujinaka W, et al (2005) Acute myocardial infarction due to coronary artery spasm after caesarean section. Masui 54:54–56PubMedGoogle Scholar
  34. 34.
    Larrazet F, Spaulding C, Lobreau HJ, et al (1993) Possible bromocriptine-induced myocardial infarction. Ann Intern Med 118:199–200PubMedGoogle Scholar
  35. 35.
    Hopp L, Weisse AB, Iffy L (1996) Acute myocardial infarction in a healthy mother using bromocriptine for milk suppression. Can J Cardiol 12:415–418PubMedGoogle Scholar
  36. 36.
    Castle WM, Simmons VE (1992) Coronary vasospasm and sumatriptan. BMJ 305:117–118PubMedCrossRefGoogle Scholar
  37. 37.
    Mueller L, Gallagher RM, Ciervo CA (1996) Vasospasm-induced myocardial infarction with sumatriptan. Headache 36:329–331PubMedCrossRefGoogle Scholar
  38. 38.
    Wackenfors A, Jarvius M, Ingemansson R, et al (2005) Triptans induce vasoconstriction of human arteries and veins from the thoracic wall. J Cardiovasc Pharmacol 45:476–484PubMedCrossRefGoogle Scholar
  39. 39.
    Bassi S, Amersey R, Henderson R et al (2004) Thyrotoxicosis, sumatriptan and coronary artery spasm. J R Soc Med 97:285–287PubMedCrossRefGoogle Scholar
  40. 40.
    Kleiman NS, Lehane DE, Geyer CE Jr et al (1987) Prinzmetal's angina during 5-fluorouracil chemotherapy. Am J Med 82:566–568PubMedCrossRefGoogle Scholar
  41. 41.
    Lestuzzi C, Viel E, Picano E, et al (2001) Coronary vasospasm as a cause of effort-related myocardial ischemia during low-dose chronic continuous infusion of 5-fluorouracil. Am J Med 111:316–318PubMedCrossRefGoogle Scholar
  42. 42.
    Sestito A, Sgueglia GA, Pozzo C, et al (2006) Coronary artery spasm induced by capecitabine. J Cardiovasc Med 7:136–138CrossRefGoogle Scholar
  43. 43.
    Papadopoulos CA, Wilson H (2008) Capecitabine-associated coronary vasospasm: a case report. Emerg Med J 25:307–309PubMedCrossRefGoogle Scholar
  44. 44.
    Rezkalla SH, Kloner RA (2007) Cocaine-induced acute myocardial infarction. Clin Med Res 5:172–176PubMedCrossRefGoogle Scholar
  45. 45.
    McCord J, Jneid H, Hollander JE et al (2008) American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation 117:1897–1907PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2009

Authors and Affiliations

  • Jae-Kwan Song
    • 1
  • Eugenio Picano
    1. 1.Echo Laboratory, Asan Medical Center Department of Pulmonary and Critical Care Medicine, Asan Medical CenterUniversity of Ulsan, College of MedicineSongpa-gu SeoulRepublic of Korea

    Personalised recommendations