• autonomic nervous system
• computed tomography angiography
• coronary artery spasm
• endothelial dysfunction
• inflammation
• ischemia
• physiopathology
• vasospastic angina

• Arrhythmias
• Estrogens
• Heart failure
• Interventional cardiology
• Menopause (including HRT)

• Humans
• Female
• Coronary Vasospasm/diagnosis
• Coronary Vasospasm/complications
• Coronary Vasospasm/physiopathology
• Adult
• Myocardial Infarction/diagnosis
• Heart Transplantation
• Siblings
• Vasodilator Agents/therapeutic use
• Electrocardiography
• Heart Failure/etiology
• Coronary Angiography

• Humans
• Male
• Female
• Genome-Wide Association Study
• Aged
• Case-Control Studies
• Myocardial Infarction/genetics
• Myocardial Infarction/epidemiology
• Polymorphism, Single Nucleotide
• Ubiquitin-Protein Ligases/genetics
• Adenosine Triphosphatases/genetics
• Middle Aged
• Japan/epidemiology
• Coronary Vasospasm/genetics
• Genetic Predisposition to Disease
• Angina Pectoris, Variant/genetics
• Risk Factors

• K99 HL169733 NHLBI NIH HHS

• Humans
• Male
• Female
• Middle Aged
• Percutaneous Coronary Intervention/methods
• Aged
• Angina Pectoris/epidemiology
• Angina Pectoris/therapy
• Angina Pectoris/diagnosis
• Coronary Vasospasm/physiopathology
• Coronary Vasospasm/epidemiology
• Retrospective Studies
• Incidence
• Treatment Outcome
• Patient Readmission/statistics & numerical data
• Risk Factors
• Coronary Stenosis/therapy
• Coronary Stenosis/complications
• Coronary Stenosis/epidemiology
• Coronary Stenosis/mortality
• Myocardial Infarction/therapy
• Myocardial Infarction/epidemiology
• Myocardial Infarction/complications

• Humans
• Coronary Vasospasm/chemically induced
• Ketamine/adverse effects
• Ketamine/administration & dosage
• Female
• Middle Aged
• Chest Pain/chemically induced
• Coronary Angiography

• coronary microvascular dysfunction
• coronary vasomotor disorders
• intracoronary provocative testing
• personalized therapy

• cardiogenic shock
• multi-vessel coronary artery spasms
• valsalva maneuver
• variant angina

• Male
• Humans
• Aged
• Coronary Vessels/diagnostic imaging
• Coronary Angiography/adverse effects
• Coronary Vasospasm/complications
• Coronary Vasospasm/diagnosis
• Myocardial Infarction/complications
• Nitroglycerin/therapeutic use
• Electrocardiography
• Arrhythmias, Cardiac/drug therapy

• acetylcholine
• coronary artery spasm
• ischaemia with non-obstructive coronary arteries
• vasospastic angina

• Humans
• Angina Pectoris, Variant/diagnosis
• Angina Pectoris, Variant/therapy
• Angina Pectoris, Variant/complications
• Coronary Vasospasm/diagnosis
• Coronary Vasospasm/therapy
• Coronary Vasospasm/complications
• Quality of Life
• Coronary Angiography/adverse effects
• Coronary Artery Disease
• Myocardial Infarction
• Chest Pain/complications
• Spasm/complications

• Angina Pectoris
• CORONARY ARTERY DISEASE
• Coronary Angiography
• EPIDEMIOLOGY
• GENETICS

• Humans
• Coronary Vasospasm/diagnosis
• Coronary Vasospasm/therapy
• Muscle Spasticity
• Angina Pectoris/diagnosis
• Angina Pectoris/etiology
• Angina Pectoris/therapy
• Myocardial Ischemia

• anesthetic management
• coronary artery spasm
• myocardial ischemia
• prinzmetal angina
• variant angina

• Coronary vasospasm
• MI with non-obstructive coronary arteries
• acetylcholine
• coronary reactivity testing
• ischemia with non-obstructive coronary arteries

• Humans
• Coronary Vasospasm/diagnosis
• Coronary Vasospasm/therapy
• Muscle Spasticity
• Angina Pectoris, Variant
• Angina Pectoris/diagnosis
• Angina Pectoris/therapy
• Myocardial Ischemia
• Coronary Angiography

• INOCA
• coronary microcirculation
• endothelial dysfunction
• inflammation
• microvascular angina

• coronary artery vasospasm
• endothelial dysfunction
• intracoronary provocation testing
• vasospastic angina

• Angiography
• Calcium channel blocker
• Coronary artery bypass grafting
• Coronary artery spasm

• Angina pectoris, variant/etiology
• coronary disease/therapy
• coronary vasospasm/complications/diagnosis/drug therapy/etiology
• coronary vessels/pathology
• risk factors
• treatment outcome
• vasoconstriction/physiology

급성 관동맥 증후군(acute coronary syndrome)은 대부분 죽상경화 관상동맥 질환(atherosclerotic coronary artery disease)에 의해 발생하지만, 비죽상경화 관상동맥 질환에서도 발생할 수 있다. 고식적 관상동맥 혈관조영술은 동맥 내강의 협착이나 확장 등의 형상에 대한 정보만을 제공하고, 동맥경화반이나 동맥벽에 대한 평가가 어려워 관상동맥 이상의 원인 질환의 진단에 낮은 특이도를 보인다. 반면, 관상동맥 전산화단층촬영 혈관조영술은 혈관경화반의 특징, 혈관벽의 조영증강뿐 아니라 연접한 대동맥이나 폐동맥의 변화 등도 함께 관찰할 수 있어, 비죽상경화 관상상동맥질환의 진단 및 다양한 원인 감별에 도움이 된다. 따라서 이 종설에서는 다양한 비죽상경화 관상동맥 질환들을 소개하고, 이의 병태생리 및 대표적인 관상동맥 전산화단층촬영 혈관조영술의 영상 소견에 대해 설명하고자 한다.

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA), as the name implies, is an acute myocardial infarction (MI) in the absence of significant coronary artery obstruction. Diagnosis and management of such cases have been challenging. There are many etiologies of MINOCA including coronary artery spasm, coronary microvascular dysfunction, plaque disruption, spontaneous coronary thrombosis or emboli, spontaneous coronary artery dissection, or cardiomyopathies. In this paper, the pathophysiology, diagnostic work-up, and clinical management for each subtype are described, and an overarching approach on how to evaluate and manage a patient presenting with MINOCA.

• Coronary artery spasm
• Coronary plaque disruption
• MINOCA
• Pathophysiology

• Gender difference
• High-density lipoprotein cholesterol
• Smoking
• Vasospastic angina

Background: Vasospastic angina (VA), or Prinzmetal’s angina, is characterized by symptoms of coronary angina caused by coronary vasospasm, usually in the absence of atherosclerotic changes. It typically presents with chest pain, which can be accompanied by transient electrocardiographic changes, if visualized during the attack. It can also rarely present with severe manifestations of acute myocardial angina, ventricular fibrillation, or cardiac arrest.

Case presentation: We present a case of a 50-year-old Caucasian male who initially presented to the hospital with chest pain and was diagnosed with VA. Later, he was brought to the hospital by emergency medical services later with ventricular fibrillation, despite normal coronary anatomy on angiogram. He was managed with placement of an intra–cardiac defibrillator (ICD) for secondary prevention. The patient continued to have recurrent episodes of ventricular fibrillation with associated ICD shocks, and had multiple admissions to the hospital with similar presentations. Symptoms and arrhythmia improved after optimizing antianginal therapy.

Conclusions: Ventricular fibrillation can be an uncommon but severe manifestation during VA crises. In cases with normal coronary vasculature, it is important to recognize VA as a cause of recurrent ventricular fibrillation in order to optimize medical management for prevention of fatal arrhythmias.

• Ventricular fibrillation
• acute coronary syndrome
• cardiac arrest
• case report
• unstable angina
• variant angina
• vasospastic angina

• Automatic implantable cardioverter defibrillators
• Prinzmetal angina
• calcium channel blocker
• coronary artery vasospasm
• nitrates
• nitroglycerin
• type 2 myocardial infarction

An 80-year-old man presented to our hospital complaining of loss of appetite. During the medical examination, he developed variant angina accompanied with heart failure. Oral calcium channel blocker therapy controlled his variant angina, but medical management of heart failure became increasingly difficult due to gradually increasing pericardial effusion, and pericardiocentesis leading to the diagnosis of effusive-constrictive pericarditis (ECP). Here, we report a rare case of idiopathic pericarditis caused variant angina with already having endothelial dysfunction and eventually developed ECP.

• effusive-constrictive pericarditis
• heart failure
• pericarditis
• variant angina

Moyamoya disease (MMD) is characterized by progressive steno-occlusive lesions of the distal or proximal branch of the internal carotid arteries, and cerebrovascular symptoms are its major complications. Extracranial vascular involvement including the coronary artery has been reported, and some case reports have described variant angina or myocardial infarction. However, no report has yet described a case of myocardial infarction after coronary artery bypass grafting (CABG). Here, we present a patient with MMD who suffered cardiac arrest caused by myocardial infarction due to a coronary spasm after off-pump CABG and who was discharged successfully after treatment with a veno-arterial extracorporeal membrane oxygenator and percutaneous coronary intervention.

• Coronary artery bypass surgery
• Coronary artery disease
• Coronary vasospasm
• Moyamoya disease

The underlying pathophysiology of coronary artery spasm (CAS) remains unclear. We aim to determine whether coronary artery medial layer thickness is associated with CAS using optical coherence tomography.

A total of 50 patients with previous myocardial infarction underwent optical coherence tomography of the left anterior descending artery: 20 with CAS and 30 without CAS. Intimal and medial layer areas were measured by planimetric analysis of optical coherence tomography images. The medial area/external elastic membrane (EEM) area was significantly greater in patients with than without CAS (0.13±0.01 versus 0.09±0.01, respectively, P<0.01), whereas the intimal area/EEM area was similar in the 2 groups. In patients without CAS, the relationship of intimal area/EEM area with medial area/EEM area and coronary diameter response to intracoronary injection of acetylcholine was characterized by an inverted U‐shaped curve (y=−1.85x²+0.81x+0.01, R²=0.43, P<0.001) and a U‐shaped curve (y=2993.2x²−1359.6x+117.1, R²=0.53, P<0.001), respectively. Thus, the medial layer became thin and the contractile response became weak in coronary arteries with greater intimal area in the non‐CAS patients. In contrast, in patients with CAS, the intimal area/EEM area had no significant relationship with the medial area/EEM area in either linear correlation analysis or quadratic regression analysis. Thus, even when the intimal layer thickened, the medial layer did not thin in patients with CAS.

The structural thickness of the coronary medial layer was increased in patients with CAS, which may provide mechanistic insight into the pathogenesis of CAS.

URL: https://www.upload.umin.ac.jp; Unique identifier: UMIN000018432.

• coronary atherosclerosis
• coronary spasm
• coronary vasomotion
• optical coherence tomography
• smooth muscle

Coronary artery spasm is a major cause of myocardial ischemia. Although coronary artery spasm has been known for a long time, its mechanism has not yet been identified. Many clinicians, especially young clinicians pay less attention to coronary artery spasm, which may lead to some patients not being appropriately diagnosed and treated in time. We report a patient with spontaneous multivessel coronary artery spasm for more than 30 years diagnosed with intravascular ultrasound (IVUS) imaging.

A 66-year-old Chinese male patient had chest squeezing at rest for more than 30 years. He had a history of cigarette smoking for more than 40 years and hypertension for 10 years. Before presenting at our institution, the patient had undergone coronary angiography 4 times and percutaneous transluminal coronary angioplasty procedures twice at other hospitals without a diagnosis of coronary artery spasm. However, his chest symptoms worsened. Spontaneous multivessel coronary artery spasm occurred during IVUS without provocation testing, and the IVUS image was recorded. Thus, the diagnosis of multifocal spontaneous coronary artery spasm was confirmed. The patient was placed on oral diltiazem, isosorbide mononitrate, and nicorandil to suppress coronary artery spasms. All medications were given at the maximum dosages tolerated by the patient. He was discharged after 5 d without complications. During the six-month follow-up period, the patient was symptom-free.

Coronary artery spasm is still prevalent in Eastern countries. It is essential for clinicians to be aware of coronary artery spasm, which may be hard to detect and can be lethal, in order to diagnose and treat patients appropriately.

• Coronary artery spasm
• Multivessel coronary
• Spontaneous
• Intravascular ultrasound
• Case report

• Calcium Channel Blockers/pharmacology
• Cardiac Imaging Techniques/methods
• Coronary Vasospasm/etiology
• Coronary Vasospasm/physiopathology
• Coronary Vasospasm/therapy
• Humans
• Myocardial Revascularization/methods
• Risk Factors

Myocardial infarction with no obstructive coronary atherosclerosis (MINOCA) is a distinct clinical syndrome characterized by evidence of myocardial infarction with normal or near-normal coronary arteries on angiography (stenosis severity < 50%). Coronary artery spasm, as seen in “variant angina,” usually occurs at a localized segment of an epicardial artery. Here, we present a case of a 58-year-old male who had norepinephrine-induced coronary vasospasm which resulted in ST elevation myocardial infarction on two consecutive admissions.

• coronary vasospasm
• myocardial infarction with no obstructive coronary atherosclerosis
• norepinephrine
• st elevation myocardial infarction

Prinzmetal's angina is a vascular spasm of the coronary artery that can mimic acute coronary syndrome. It is rarely responsible for ventricular arrhythmias and cardiac arrest; however, survivors with these complications are at increased risk for recurrent ventricular arrhythmias and sudden cardiac death. This is true despite the presence of normal cardiac function and optimal medical therapy. Thus, this select population should be considered for an implantable cardioverter defibrillator (ICD). In this case vignette, we describe a healthy 48-year-old female with ventricular fibrillation arrest, followed by recurrent ventricular tachyarrhythmias caused by Prinzmetal's angina.

• MI with non-obstructive coronary artery
• ST-segment elevation MI
• acute coronary syndrome

Genetic factors and lifestyle exposures, as well as their combinations, play important roles in the development of hypertension. We examined whether cigarette smoking, alcohol drinking and the Glu298Asp polymorphism of the endothelial nitric oxide synthase (eNOS) gene generate combined effects on blood pressure (BP) in hypertensive subjects.

A total of 342 essential hypertensive subjects were recruited from Susong community in Anhui province, China, from July 2017 to January 2018, and the plasma biochemical parameters and the genotype on Glu298Asp polymorphism were determined.

There were no gender differences in the distributions of alleles and genotypes in hypertensive subjects. The proportions of cigarette smoking and alcohol drinking in male hypertensive subjects were remarkably higher than those in the females (p<0.001). The systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels of mutant genotypes (Glu/Asp and Asp/Asp) were significantly higher than those of wild genotype (Glu/Glu) (p=0.013 and 0.026, respectively) in male hypertensive subjects. Moreover, the SBP and DBP levels of the mutant genotype were remarkably higher than those of wild genotype in both cigarette smoking and alcohol drinking male hypertensive subjects (p=0.034 and 0.043, respectively).

Cigarette smoking, alcohol drinking and the Glu298Asp polymorphism of the eNOS gene generate combined effects that increase the susceptibility of the mutant genotype to BP in Chinese male hypertensive subjects.

• Glu298Asp polymorphism
• alcohol drinking
• blood pressure
• cigarette smoking
• combined effect

• acute coronary syndrome
• nstemi
• prinzmetal angina
• refractory vasospastic angina
• stemi
• vasospastic angina

Currently, there is no validated multivariate model to predict probability of coronary artery spasm (CAS) in patients with acute chest pain.

A total of 976 consecutive patients with acute chest pain were enrolled. Patients were divided into two groups based on the presence of significant CAS. To adjust potential confounders, a multivariable analysis was performed and a clinical diagnostic score system for CAS was utilized for score derivation.

Multivariable analysis model selected 6 predictors for CAS. The integer score was assigned to each predictors: angina at rest alone (10 points), positive of hyperventilation test (8 points), allergies (3 points), asthma, ST-segment elevation and myocardial bridge (2 points each). We showed that the clinical diagnostic score system had accuracy in predicting CAS, as measured by the area under the curve (AUC), which was 0.952–0.966. The cut-off baseline value for the clinical diagnostic score system was set to 11–12 points with specificity of 91.0–93.3% and sensitivity of 90.7–92.9%, respectively.

A clinical diagnostic score system was derived and validated as an accurate tool for estimating the pretest probability of CAS in patients with acute chest pain.

• Acute chest pain
• Clinical diagnostic score system
• Coronary artery spasm

• Coronary artery disease
• Myocardial infarction
• Non-obstructive coronary atherosclerosis
• Vasospastic angina

• Acute myocardial infarction
• Coronary artery spasm
• Prognosis

• Angor
• Angor vasospastique
• Prinzmetal
• Variant angina
• Vasospasm
• Vasospasme
• Vasospastic angina

• Focal spasm
• Single vessel spasm
• Vasospastic angina

• Adult
• Aged
• Coronary Angiography/methods
• Coronary Stenosis/chemically induced
• Coronary Stenosis/diagnostic imaging
• Coronary Vasospasm/chemically induced
• Coronary Vasospasm/diagnostic imaging
• Coronary Vessels/diagnostic imaging
• Coronary Vessels/drug effects
• Ergonovine/administration & dosage
• Ergonovine/adverse effects
• Follow-Up Studies
• Humans
• Infusions, Intra-Arterial
• Male
• Middle Aged
• Oxytocics/administration & dosage
• Oxytocics/adverse effects
• Prospective Studies
• Registries
• Treatment Outcome

• angina
• calcium channel blocker
• cardiology
• coronary spasm
• interventional
• nitroglycerin

It is widely accepted that progression of organic stenosis in the coronary arteries and onset of acute coronary syndrome (ACS) are similar in the development of atherosclerosis. However, the extent of the association of each risk factor with the respective pathological conditions has not been fully elucidated.

We investigated the differences in risk factors between these conditions using a statistical procedure.

The study population consisted of 1,029 patients with ischemic heart disease (IHD). We divided the study population into two groups (ACS and non-ACS) and by diseased vessels (organic stenosis). Covariance structure analysis was simultaneously performed in one equation model for determination and comparison of the risk factors for organic stenosis and ACS.

The analysis revealed that age (standardized regression coefficient, β: 0.206, P < 0.001), male gender (β: 0.126, P < 0.001), HbA1c level (β: 0.109, P < 0.001), HDL level (β: -0.109, P < 0.001) and LDL level (β: 0.127, P = 0.002) were significant for the advancement of organic stenosis. HDL level (β: 0100, P = 0.002) and MDA-LDL level (β: 0.335, P < 0.001) were significant for the onset of ACS, but age, HbA1c and LDL (P = NS or β < 0.1, respectively) were not. Among the risk factors, age, HbA1c and LDL were significantly more strongly associated with organic stenosis than ACS, while MDA-LDL was significantly more strongly associated with ACS than organic stenosis.

The current statistical analysis revealed clear differences among the risk factors between the progression of organic stenosis and the onset of ACS. Among them, the MDA-LDL level should be considered to indicate a substantial risk of ACS.

Cigarette smoking is a risk significant factor in coronary artery disease (CAD) and vasospastic angina (VSA). However, it is largely unknown whether smoking adds to any long-term clinical risk in VSA patients.

A total of 2797 patients without significant CAD underwent acetylcholine (Ach) provocation test between November 2004 and October 2010. Patients were divided into three groups, based on the presence of coronary artery spasm (CAS) and smoking habits (non-CAS group: n=1188, non-smoking CAS group: n=1214, smoking CAS group: n=395). All CAS patients were prescribed with anti-anginal medications for at least 6 months. The incidence of major clinical outcomes and recurrent angina of these groups were compared up to 3 years.

There were considerable differences in the baseline clinical and angiographic characteristics among the three groups, but there was no difference in the endpoints among the three groups (including individual and composite hard endpoints) such as death, myocardial infarction, de novo percutaneous coronary intervention, cerebrovascular accident, and major adverse cardiac events. However, there was a higher incidence of recurrent angina in both the non-smoking CAS group and smoking CAS group, as compared to the non-CAS group. In multivariable adjusted Cox-proportional hazards regression analysis, smoking CAS group exhibited a higher incidence of recurrent angina compared with the non-CAS group (hazard ratio [HR]; 2.46, 95% confidence interval [CI]; 1.46-4.14, p=0.001) and non-smoking CAS group (HR; 1.76, 95% CI; 1.08-2.87, p=0.021).

Cigarette smoking CAS group exhibited higher incidence of recurrent angina during the 3-year clinical follow-up compared with both the non-CAS group and non-smoking CAS group. Quitting of smoking, paired with intensive medical therapy and close clinical follow-up, can help to prevent recurrent angina.

• Cigarette smoking
• Clinical outcome
• Coronary artery spasm

• Aged
• Angina Pectoris/etiology
• Asthma/complications
• Cohort Studies
• Coronary Vasospasm/etiology
• Female
• Humans
• Male
• Middle Aged
• Retrospective Studies