Importance of a second spasm provocation test: Four cases with an initial negative spasm provocation test

Figure 1 Coronary angiograms during the first and second spasm provocation test in case 1. A: The first spasm provocation test (SPT) showed negative results after intracoronary infusions of acetylcholine (ACh) with 50 µg for the right coronary artery (RCA) and 100 μg for the left coronary artery (LCA); B: The second SPT showed positive RCA results with an infusion of 30 μg ACh, accompanied by the usual chest symptoms and electrocardiogram changes, despite negative LCA results after an intracoronary infusion of nitroglycerin (NTG). Arrows indicate coronary spasm.

Figure 2 Coronary angiograms during the first and second spasm provocation test in case 2. A: The first spasm provocation test (SPT) showed moderate vasoconstriction of the right coronary artery (RCA) after infusions of 50 μg acetylcholine (ACh) and moderate left coronary artery (LCA) vasoconstriction after infusions of 100 μg ACh. However, neither chest symptoms nor ST deviation of the electrocardiogram occurred during the SPT; B: The second SPT showed positive results with both the RCA after intracoronary infusions of 50 μg ACh and the LCA after infusions of 100 μg ACh, accompanied by the usual chest symptoms. Arrows indicate coronary spasms.

Figure 3 Coronary angiograms during the first and second spasm provocation test in case 3. A: The first spasm provocation test (SPT) showed negative right coronary artery (RCA) results after an intracoronary infusion of 50 µg acetylcholine (ACh) and of the left coronary artery (LCA) after an intracoronary infusion of 100 μg Ach; B: The second SPT also showed negative RCA results after an intracoronary infusion of 80 μg ACh and of the LCA after an intracoronary infusion of 200 μg ACh.

Figure 4 Coronary angiograms during the first and second spasm provocation test in case 4. A: The first spasm provocation test (SPT) showed negative right coronary artery (RCA) results after an intracoronary infusion of 50 μg acetylcholine (ACh) and of the left coronary artery (LCA) after an intracoronary infusion of 100 μg Ach; B: The second SPT showed negative RCA results after an intracoronary infusion with 50 µg ACh, and severe vasoconstriction at the distal left anterior descending coronary artery, after an intracoronary infusion of 100 μg ACh. Arrows indicate coronary spasms.