Abstract
Coronary artery spasm (CAS) defined by a severe reversible diffuse or focal vasoconstriction is the most common diagnosis among INOCA (ischemia with no obstructive coronary artery disease) patients irrespective to racial, genetic, and geographic variations. However, the prevalence of CAS tends to decrease in correlation with the increasing use of medicines such as calcium channel blockers, angiotensin converting enzyme inhibitor, and statins, the controlling management of atherosclerotic risk factors, and the decreased habitude to perform a functional reactivity test in highly active cardiac catheterization centers. A wide spectrum of clinical manifestations from silent disease to sudden cardiac death was attributed to this complex entity with unclear pathophysiology. Multiple mechanisms such as the autonomic nervous system, endothelial dysfunction, chronic inflammation, oxidative stress, and smooth muscle hypercontractility are involved. Regardless of the limited benefits proffered by the newly emerged cardiac imaging modalities, the provocative test remains the cornerstone diagnostic tool for CAS. It allows to reproduce CAS and to evaluate reactivity to nitrates. Different invasive and noninvasive therapeutic approaches are approved for the management of CAS. Long-acting nondihydropyridine calcium channel blockers are recommended for first line therapy. Invasive strategies such as PCI (percutaneous coronary intervention) and CABG (coronary artery bypass graft) have shown benefits in CAS with significant atherosclerotic lesions. Combination therapies are proposed for refractory cases.
Highlights
Coronary artery spasm (CAS), which is a reversible vasoconstriction driven by a spontaneous vascular smooth muscle hypercontractility and vascular wall hypertonicity narrowing the lumen of normal or atherosclerotic coronary arteries compromising the myocardial blood flow, is recognized recently under the chapter of myocardial infarction with nonobstructive coronary arteries (MINOCA) [1, 2]
E concept of CAS was first postulated by Prinzmetal et al by describing a nonexertional angina occurring at rest or during regular daily activities [3], which could not be explained by an increase in myocardial oxygen demand unlike the classical angina of Heberden induced by an emotional or physical stress and relieved by exercise cessation or nitrates [7, 8]. us, they proposed an underlying culprit vasospasm reducing blood supply to a localized myocardial area [3] that explains the remarkable accompanied electrical changes such as transient ST segment elevation or depression in the corresponding leads [9, 10]
CAS is more common in males than females [5, 18], individuals aged between 40 and 70 years [5, 18], and more in Japanese (24.3%) followed by Taiwanese (19.3%) and Caucasian (7.5%) populations [19]. e widespread use of calcium channel blockers, statins, angiotensin II receptor blockers, and converting enzyme inhibitors, smoking awareness campaigns, and declining tendency of physicians to carry out coronary vasoreactivity tests contribute to a reduction in CAS prevalence, in Japan [20, 21]
Summary
Coronary artery spasm (CAS), which is a reversible vasoconstriction driven by a spontaneous vascular smooth muscle hypercontractility and vascular wall hypertonicity narrowing the lumen of normal or atherosclerotic coronary arteries compromising the myocardial blood flow, is recognized recently under the chapter of myocardial infarction with nonobstructive coronary arteries (MINOCA) [1, 2]. Several features were attributed to this complex ischemic entity over time passing by “A variant form of angina pectoris or variant angina” [3], “variant of the variant” [4], “coronary vasospastic angina” [5], “a false-positive STEMI” [1], and “forgotten coronary disorder” [6]. The coronary artery spasm hypothesis was confirmed and demonstrated in several experimental studies, especially after the introduction of either the provocative test that induces vasospasm [6, 11] or coronary angiography that illustrates spasm on the epicardial coronary artery in patients with vasospastic angina [4, 12, 13]. Journal of Interventional Cardiology subclinical entity known as “Kounis syndrome” and the latest development in the diagnostic modalities such as CMRI, IVUS, and OCT
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