Diffuse Spasm Research Articles

Coronary Microvascular Vasodilatory Function: Related Clinical Features and Differences According to the Different Coronary Arteries and Types of Coronary Spasm.

Background: In the clinical setting; the microvascular vasodilatory function test (MVFT) with a pressure wire has been used in ischaemia patients with non-obstructive coronary arteries (INOCA), including vasospastic angina (VSA) and microvascular angina (MVA). The exact factors that affect the microvascular vasodilatory function (MVF) in such patients are still unknown. We aimed to identify the factors, including clinical parameters and lesion characteristics, affecting the MVF in such patients. Methods: A total of 53 patients who underwent coronary angiography, spasm provocation tests (SPTs) and MVFTs were enrolled. In the MVFT, the coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) were measured. Of the 53 patients, MVFT data in the left anterior descending coronary artery (LAD) were obtained from 49 patients, and the clinical parameters were checked in all of them. Based on the results of the SPT, coronary spasms were divided into focal spasm, diffuse spasm, and microvascular spasm (MVS). To assess the lesion characteristics influencing MVF, MVFT data were compared according to the types of coronary spasm and coronary vessels in 73 vessels of the 53 patients. Results: In 49 patients who underwent the MVFT in the LAD, the IMR was higher in active smokers (n = 7) than in former smokers (n = 15) and never smokers (n = 27, p < 0.01). In the 73 coronary arteries in this study, the type of coronary spasm did not correlate with the CFR or IMR, whereas a higher IMR were more frequently observed in cases of focal spasm than in cases of diffuse spasm (p = 0.03). In addition, the IMR was higher in the right coronary artery (RCA) than in the LAD (p = 0.02). Conclusion: These results indicate that the smoking status affected the MVF in patients with INOCA, suggesting the possibility of improvement in the MVF by smoking cessation in such patients. In addition, in the assessment of MVF, it may be important to take into account which coronary artery or types of coronary spasm are being evaluated.

Coronary microvascular function in patients with angina with no obstructive coronary artery disease-What factors affect it clinically or angiographically?

Abstract Background In the clinical setting, we have often experienced patients with angina with no obstructive coronary artery disease (ANOCA), and it has been proposed that the presence of coronary microvascular dysfunction (CMD) play a pivotal role in the pathogenesis of ANOCA. Thus, it is important to assess coronary microvascular function (CMF). However, it has not been clarified what clinical factors or lesion characteristics on coronary angiography (CAG) affect CMF. Thus, we investigated the relationship between CMF and clinical factors or lesion characteristics on CAG in patients with ANOCA. Methods Thirty-four patients with chest pain, who underwent CAG, spasm provocation test (SPT) and CMF test, were enrolled. We excluded patients who had moderate coronary stenosis (% stenosis &amp;gt;30%). In the SPT with acetylcholine for left coronary artery and right coronary artery (RCA), the coronary spasm was defined as &amp;gt;90% narrowing of coronary artery on CAG accompanied with chest symptoms and/or ST-T changes on ECG during SPT, and coronary microvascular spasm (MVS) was defined as ≤90% narrowing of coronary artery on CAG with accompanied with chest pain and ST-T changes during SPT. In each coronary artery, the presences of atherosclerosis (20%≤%stenosis≤30%), focal spasm (spasm occurred within one segment of AHA classification), diffuse spasm (spasm occurred over two segments of AHA classification) and MVS, were checked. In the CMF test with a pressure-wire during adenosine triphosphate infusion, the index of microvascular resistance (IMR) was measured. IMR values were obtained in 34 of the left anterior descending coronary artery (LAD) and 12 in RCA. In each patient, conventional coronary risk factors, blood chemical parameters, peripheral endothelial function such as flow-mediated dilation (FMD) of brachial artery and left ventricular mass index (LVMI) were checked. Results In 34 patients, clinical factors including blood chemical parameters, FMD and LVMI, except for smoking status did not affect IMR values on LAD. Only the smoking status was associated with IMR values as follows: median IMR values were 44, 22 and 25 in current smokers (n=5), past smokers (n=8) and never smokers (n=21, p=0.03), respectively. In 46 coronary arteries, the presence of atherosclerosis, the type of the coronary spasm, such as focal and diffuse spasm and MVS, did not affect the IMR values, however, it was significantly higher in the RCA (median 38) than that in the LAD (median 26, p=0.02). Conclusion These results suggest that smoking status affected CMF in patients with ANOCA, suggesting the possibility of improvement of CMF by stop smoking in such patients. In addition, in the assessment of CMF, it may be important to take into account which coronary artery being evaluated. Funding Acknowledgement Type of funding sources: None.

Cover Image

The cover image is based on the Case Report Widespread ST-segment elevation due to diffuse coronary artery spasm: A case report by Lin Bai, Fei Chen, and Yong Peng., https://doi.org/10.1111/anec.12877.

B-AB19-04 DIAGNOSIS OF CORONARY VASOSPASM-INDUCED VENTRICULAR FIBRILLATION DURING PERICARDIAL MAPPING

After excluding cardiac genetic and structural abnormalities, idiopathic VF is estimated to account for ∼5% of cases of sudden cardiac death. In these cases, it may be difficult to identify an etiology for VF. We present a case of idiopathic polymorphic VT/VF (pVT/VF) with the diagnosis made in the EP lab. N/A A 47-year-old man had a witnessed cardiac arrest and was found to be in VF. A work-up including coronary angiography was unrevealing; MRI was largely normal, though suggestive of an inferolateral area of subepicardial scar. A subcutaneous ICD (SICD) was placed. He presented to us with recurrent pVT/VF on sotalol resulting in multiple ICD shocks, some of which failed to immediately defibrillate. At EP study, stimulation did not induce sustained ventricular arrhythmias. Standard pericardial access was obtained to permit epi/endo mapping to identify arrhythmogenic substrate. But immediately upon onset of pericardial mapping, ST segment elevation occurred, and the patient developed non-sustained pVT (Figure). Immediate coronary angiography revealed diffuse coronary spasm, most strikingly in the proximal LAD. With administration of intracoronary nitroglycerin, the LAD spasm and pVT/VF resolved; ST segment abnormalities resolved within minutes. DFT testing revealed a normal functioning SICD. He was discharged on long-acting nifedipine and nitrates for coronary vasospasm. Severe coronary vasospasm may cause idiopathic polymorphic VT/VF. Medical therapy with calcium-channel blockers and oral nitrates are the first-line therapy as ICD therapies alone may be ineffective in the setting of on-going spasm and ischemia.

Widespread ST‐segment elevation due to diffuse coronary artery spasm: A case report

Coronary artery spasm (CAS) is considered an important mechanism of acute coronary syndrome but not very common in the clinical setting. We report a case of a 42‐year‐old woman with chest pain lasting for 4 h due to diffuse CAS, which led to widespread ST‐segment elevation in multiple leads of the electrocardiogram and elevated cardiac troponin T. Emergency coronary angiography at admission showed significantly different morphological results from the second angiography during hospitalization, indicating the patient's discomfort was due to CAS rather than stenosis. Our case illustrates that diffuse CAS can cause widespread ST‐segment elevation and severe ACS.

CASE OF CORONARY ARTERY SPASM WITH FATAL OUTCOME IN THE EARLY PERIOD AFTER PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY OF THE RIGHT CORONARY ARTERY WITH IMPLANTATION OF BARE METAL STENTS

The paper presents a clinical case of coronary artery spasm after implantation of bare metal stents. The 60-year-old man was admitted to the hospital with the progression of the coronary heart disease and high angina pectoris functional class for coronary angiography. The patient had the main predisposing factor for the development of coronary artery spasm, which is 20-year smoking history. Based on the results of the coronary angiography, the decision was made to conduct endovascular treatment. The patient was discharged on the 2 nd day after angioplasty with implantation of two stents in the right coronary artery. On the evening of discharge, the man developed a severe pain attack in the epigastric region and turned to the hospital. The electrocardiogram revealed ST-segment elevation in leads II, III, aVF, T-waves were negative in leads I, aVL and V3-6. Repeat coronary angiography showed the stent implantation sites were passable, there was a pronounced diffuse coronary artery spasm, which could not be eliminated by intracoronary administration of nitroglycerin. Coronary artery spasm induced by coronary angioplasty with stent placement is a rare complication that can develop at different time intervals after endovascular intervention. Based on the presented clinical case, it appears likely that even after bare metal stents implantation, the development of endovascular dysfunction leading to coronary spasm is possible.

Prognostic Links Between OCT-Delineated Coronary Morphologies and Coronary Functional Abnormalities in Patients With INOCA.

Whether there are prognostic links between coronary morphologies and coronary functional abnormalities was examined in ischemia and nonobstructive coronary artery disease (INOCA) patients. Although INOCA has attracted much attention, little is known about the prognostic impact of coronary morphologies in this disorder. A total of 329 consecutive INOCA patients were enrolled and underwent spasm provocation testing combined with lactate sampling for diagnosis of epicardial and microvascular spasm (MVS). On the basis of the functional tests, the patients were classified into 4 groups: a control group without epicardial spasm or MVS (n=32), MVS alone (n=51), diffuse spasm in≥2 coronary segments (n=204), and focal spasm in 1 segment (n=42). In this population, optical coherence tomography imaging of the left anterior descending coronary artery was performed for evaluation of adventitial vasa vasorum (AVV) and intraplaque neovessels (IPN). Index of microcirculatory resistance was also measured. MVS frequently coexisted with diffuse (70%) and focal spasm (68%) with a good correlation between AVV and index of microcirculatory resistance (R=0.353; p=0.022). For a median follow-up of 1,043days, focal spasm showed the worst prognosis (log rank p=0.005), for which IPN was a significant prognostic factor. By contrast, diffuse spasm showed the greatest AVV with an intermediate prognosis. The prognostic value of INOCA was significantly enhanced by adding AVV and IPN to the physiological indices (area under the curve=0.88 vs. 0.76; p=0.048). These results provide the first evidence that there are important prognostic links between coronary morphologies (evaluated by optical coherence tomography) and coronary functional abnormalities in patients with INOCA, indicating the importance of both evaluations in this population.

Clinical implications of coronary artery morphology of patients with ischemia and non-obstructive coronary artery disease (INOCA) -An intracoronary OCT study-

Abstract Introduction Ischemia and non-obstructive coronary artery disease (INOCA), including microvascular spasm (MVS) and epicardial spasm, has recently attracted much attention, for which in vivo imaging evaluation for coronary artery morphology is warranted for better understanding of this disorder. Besides the improved diagnostic accuracy of optical coherence tomography (OCT) for coronary plaques, we have recently demonstrated its capability for in vivo visualization of coronary adventitial vasa vasorum (VV) and the enhanced VV formation in patients with epicardial spasm. Purpose We aimed to examine OCT-delineated morphological characteristics in patients with INOCA in vivo. Methods A total of 335 consecutive INOCA patients, who underwent pharmacological spasm provocation tests, lactate sampling, and OCT imaging over the entire length of the left anterior descending (LAD) coronary arteries, were enrolled at our institute over 68 months from April 2013. They were classified into 4 groups; control with non-cardiac chest pain, MVS, diffuse spasm (DS), or focal spasm (FS) (Fig. 1A). MVS was diagnosed when negative lactate extraction ratio (coronary orifice &amp;lt; coronary sinus) was detected despite the absence of epicardial spasm during the spasm provocation test. DS was defined as epicardial spasm induced in more than 2 coronary segments in LAD, and FS as epicardial spasm in one segment. Quantitative analyses for adventitial inflammation and atherosclerotic changes were performed by calculating VV density and %area stenosis (AS) on OCT (Fig. 1B, E). Furthermore, index of microcirculatory resistance (IMR), a marker of microvascular disorder with a cut-off value of ≥25, was measured during intravenous infusion of adenosine, which was then correlated with VV densities in the MVS and DS groups. Coronary plaque with a necrotic core was classified as fibroatheroma (FA), and the number of OCT frames with internal VV (IVV) in the atheroma was counted. Results VV density was significantly higher in MVS as compared with the controls (Fig. 1B). DS was most prevalent in INOCA (Fig. 1A) with highest VV density (Fig. 1B). Patients with IMR≥25 were predominantly distributed with a gradual increase in the MVS, DS, and FS groups, but none in the controls (Fig. 1C). Importantly, there was a significant positive correlation between VV densities and IMR in the MVS and DS groups (Fig. 1D). In addition, FS had the largest plaque size and showed the highest prevalence of FA and IVV (Fig. 1E–G). Conclusions These results indicate that MVS and DS are characterized by vasomotion abnormalities associated with adventitial inflammation and microvascular disorder, while FS by vulnerable atherosclerotic phenotype, suggesting that OCT may be useful for screening high-risk populations in INOCA. Figure 1 Funding Acknowledgement Type of funding source: None

Assessment of coronary vasomotor responses to acetylcholine in German and Japanese patients with epicardial coronary spasm-more similarities than differences?

Coronary spasm is an established cause for angina pectoris. Ethnic differences have been suggested among Asian compared to Caucasian patients regarding prevalence, gender distribution, and angiographic patterns of coronary spasm. The aim of this study was to compare contemporary German and Japanese patients with coronary spasm. Between 2011 and 2015, 149 patients with resting angina and unobstructed coronary arteries with acetylcholine-induced epicardial spasm were enrolled in Stuttgart, Germany (n = 69) and Sendai, Japan (n = 80). All patients underwent intracoronary acetylcholine testing according to a standardized protocol. Comprehensive analysis included type of spasm (focal/diffuse), dose of acetylcholine leading to spasm, and frequency of multivessel spasm. Patients in this study were 61 ± 11years old, predominantly female (54%), and had normal left ventricular ejection fraction (73 ± 9%). Diffuse spasm was the most prevalent type of spasm (85%) whereas focal spasm was found in the remaining 15% of patients. 31% of patients had multivessel spasm. Comparing the German with the Japanese patients, distribution of spasm type (focal/diffuse, p = 0.19) and frequency of multivessel spasm (p = 0.22) were comparable. Moreover, when Japanese patients were compared with German patients and diffuse spasm with focal spasm patients, respectively, no significant differences were observed regarding the acetylcholine dose required to induce spasm (p = 0.078 and p = 0.46, respectively). In conclusion, diffuse epicardial coronary spasm is the most frequent finding among German and Japanese patients with resting angina, unobstructed coronary arteries, and epicardial spasm on acetylcholine testing. Japanese and German patients share several similarities including comparable types of spasm and frequency of multivessel spasm.

Catheter-induced Multiple Non-proximal Coronary Spasm in a Patient Presenting with Myocardial Infarction

Interventional cardiologists encounter a wide range of lesions that cannot be angiographically distinguished from fixed atherosclerotic obstructive disease. In this case report, we document vasospasm at multiple sites in the coronary territory in a patient presenting with acute coronary syndrome. A 61-year-old woman was referred to our hospital with typical chest pain lasting approximately 1 h. After performing the left coronary artery angiography, a severe tubular stenosis was detected in circumflex (Cx) artery. Diffuse spasm was observed in the right coronary artery (RCA) and it resolved after intracoronary administration of nitroglycerin. After performing left system angiography again, severe stenosis in Cx artery was also completely resolved. Our finding is of clinical importance in that it is more likely to simulate a constant coronary stenosis than would have spasm occurred proximally. The clinical importance of our report is that a catheter-induced vasospasm (CIV) may simulate fixed coronary stenosis, not always osteally and in some instances at multiple sites. Awareness of this phenomenon and liberal use of nitroglycerin in any patient with discrete luminal narrowing, even when an ostial “lesion” is not present, can help to avoid misinterpreting CIV as an atherosclerotic lesion.

A NOVEL VARIANT OF TAKOTSUBO CARDIOMYOPATHY

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Takotsubo cardiomyopathy (TCM) is a form of nonischemic cardiomyopathy that is characterized by transient regional systolic dysfunction of the left ventricle. It often mimics acute myocardial infarction but has a minimal release of cardiac enzymes. The hallmark is an absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. In most cases of TCM, the regional wall motion abnormality extends beyond the territory perfused by a single epicardial coronary artery. Classically, TCM is associated with a ballooned left ventricular apex and basal segmental hyperkinesis. While there have been reports of atypical TCM with midventricular hypokinesia and apical sparing, here we present a novel variant in which there is left ventricular hypokinesis of the anterior, septal, and lateral segments, with preservation of motion only in the inferior wall. CASE PRESENTATION: A 56 year old female presented with recent increased stress, poor sleep, and epigastric abdominal pain with radiation to the right shoulder for 4 days. EKG showed ST elevations in V1-V4 and reciprocal ST depressions in II, III, and aVF. Troponin-T peaked to 1.250. Left heart ventricular angiogram showed a left ventricular ejection fraction (LV EF) of 10-15%, with no obstructive coronary artery disease visualized on the angiogram. Transthoracic echocardiography showed LV wall hypokinesis of the anterior, septal, and lateral segments, with preserved motion only in the inferior wall. (Fig. A - F). Follow up TTE showed improvement of LV EF to 35%. DISCUSSION: TCM is a non-ischemic cardiomyopathy with transient contractility changes, presenting in middle-aged women with acute stress. This patient’s presentation - with EKG concerning for acute ST elevation myocardial infarction, no evidence of coronary artery disease, and extensive LV cardiomyopathy - implies a diagnosis of TCM. The pathogenesis of Takotsubo cardiomyopathy is not well understood. Postulated mechanisms include catecholamine excess, coronary artery spasm, and microvascular dysfunction. It is thought that catecholamines play a role in TCM because of the correlation of the disorder with physical or emotional stress. A catecholamine surge may cause diffuse microvascular spasm or dysfunction, resulting in myocardial stunning. Catecholamines can also have a direct myocardial toxicity effect, further contributing to the cardiomyopathy. On resolution of the catecholamine surge, the myocardium recovers and LV EF improves. CONCLUSIONS: This case demonstrates a novel, as of yet unseen, variant of TCM with hypokinesis of all but the inferior wall. Such specific sparing supports etiologies of TCM not related to epicardial coronary artery distribution, and lends credence to etiologies involving stress-induced catecholamine excess causing neurogenic stunned myocardium. Reference #1: Murthy, A., Arora, J., Singh, A., Gedela, M., Karnati, P., & Nappi, A. (2014). Takotsubo Cardiomyopathy: Typical and Atypical Variants, A Two-Year Retrospective Cohort Study. Cardiology research, 5(5), 139-144. Reference #2: Velankar, P., & Buergler, J. (2012). A mid-ventricular variant of Takotsubo cardiomyopathy. Methodist DeBakey cardiovascular journal, 8(3), 37-9. DISCLOSURES: no disclosure on file for Mandeep Kainth; No relevant relationships by Sharmila Sarkar, source=Web Response No relevant relationships by Alexander Volodarskiy, source=Web Response

3332Exercise training ameliorates vasodilator capacity of coronary microvessels in patients with vasospastic angina - A new therapeutic approach for the coronary functional disorder

Abstract Background We have recently demonstrated that coronary vasospasm could develop in both epicardial coronary arteries and intramuscular coronary microvessels in patients with vasospastic angina (VSA). However, it remains to be examined whether vasodilator capacity of coronary microvessels is impaired in VSA patients and if so, whether exercise training could ameliorate vasodilator capacity of coronary microvessels on the top of calcium channel blockers. The effectiveness of exercise training is established for organic coronary artery disease but remained to be examined for VSA. Purpose We thus examined whether vasodilator capacity of coronary microvessels is impaired in VSA patients without organic coronary stenosis using an adenosine-stress dynamic computed tomography perfusion (CTP) that can measure absolute value of myocardial blood flow (MBF). We also examined whether exercise training ameliorates not only vasodilator capacity of coronary microvessels but also exercise capacity and frequency of angina attack. Methods In the first protocol, we measured MBF using CTP in consecutive 32 VSA patients with acetylcholine-induced diffuse coronary spasm in the left anterior descending coronary arteries (LAD) and 12 non-VSA controls. In the second protocol, we conducted a randomized controlled trial (RCT; Exercise VSA trial, UMIN: ehz745.008423996), where 20 VSA patients were randomly assigned to either exercise group (Ex group: supervised exercise training session for 30-min using bicycle ergometer, once/week at the hospital and more than 3 times/week at home) or non-exercise group (Non-Ex group) (n=10 each) (Figure A). Before and 3 months after exercise training, we measured MBF with adenosine-stress dynamic CTP and peak VO2 by cardiopulmonary exercise tests, and also assessed angina attack with Seattle Angina Questionnaire (SAQ). Results In the first protocol, CTP showed that adenosine-stress MBF was significantly decreased in the VSA group compared with the non-VSA group (VSA, 137.2±6.6 vs. Non-VSA, 174.4±10.7 ml/100g/min, P&lt;0.01) (Figure B), although patient characteristics were comparable between the 2 groups. In the second protocol, exercise training was performed safely in all patients, and RCT showed that MBF was significantly increased in the Ex group compared with the non-Ex group (Figures C, D), although patient characteristics were also comparable between the 2 groups. Furthermore, peak VO2 was significantly increased in the Ex group compared with the non-Ex group (Figure E), and frequency of angina was significantly decreased in the Ex group compared with the non-Ex group (Figure F). Finally, there was a significant positive correlation between the extents of the changes in peak VO2 and the SAQ score for angina frequency in the Ex group (P&lt;0.01, R=0.67). Figures Conclusions These results provide the first evidence that vasodilator capacity of coronary microvessels is impaired in VSA patients, which can be ameliorated by exercise training.

Evaluation of conservative treatment of frozen shoulder: A clinical study

The frozen shoulder (adhesive capsulitis) is a clinical syndrome complicated by a surfeit of synonyms. The true mechanism has been the grist of innumerable scholarly effort. Strangely the diagnosis is not difficult although the precise cause may be elusive. The present study was conducted upon 100 patients. The inclusion criteria was to consider patients with gradual onset with classical phasic character of the disease, pain in the shoulder joint, limitation of movements which may only be slight in the beginning and objective signs of diffuse tenderness, muscle spasm or wasting of muscles. Once the diagnosis was established, the patients were divided in to three groups which were then managed accordingly with only physiotherapy, steroid and local anaesthesia injection with physiotherapy and manipulation under anaesthesia with local steroid injection. The observations were based on a twelve week follow up study of these cases. Most of the patients were in their sixth decade of life. The mean age of the patients were 50.96 years. In our study, 58% were females whereas 42% were males. 50% of the patients had involvement of right shoulder and in the remaining 50% left shoulder was involved. Only one patient had involvement of both the shoulder joint. In our series, most of the patients came to seek medical advice after some interval from the onset. The majority of them reported between 2-4 months since the onset of symptoms, average duration being 4.3 months. There was appreciable wasting of deltoid and supraspinatus in 57 cases and muscle spasm was there in 43 cases. All the patient had pain at limits of motion. The combined results at the end of 12 weeks follow-up were; out of 100 patients and 101 shoulders (one case bilateral involvement) treated, 44 graded as excellent, 39 as good, 14 as fair and remaining four as poor. The authors believe that the patients with frozen shoulder should be diagnosed promptly and regular follow up is needed for better evaluation of their response to treatment.

Association between Ischemic Electrocardiographic Changes during Acetylcholine Provocation Test and Long-Term Clinical Outcomes in Patients with Vasospastic Angina

Objectives Intracoronary injection of acetylcholine (Ach) has been shown to induce significant coronary artery spasm (CAS) in patients with vasospastic angina. Clinical significance and angiographic characteristics of patients with ischemic electrocardiogram (ECG) changes during the Ach provocation test are not clarified yet. Methods A total 4,418 consecutive patients underwent coronary angiography with Ach provocation tests from 2004 to 2012 were enrolled. Ischemic ECG changes were defined as transient ST-segment depression or elevation ( &amp;gt; 1 mm) and T inversion with/without chest pain. Finally, a total 2,293 patients (28.5% of total subjects) proven CAS were enrolled for this study. Results A total 119 patients (5.2%) showed ECG changes during Ach provocation tests. The baseline clinical and procedural characteristics are well balanced between the two groups. Ischemic ECG change group showed more frequent chest pain, higher incidence of baseline spasm, severe vasospasm, multi-vessel involvement, and more diffuse spasm ( &amp;gt; 30 mm) than those without ischemic ECG changes. At 5 years, the incidences of death, major adverse cardiac events (MACE) and major adverse cardiac and cerebral events (MACCE) were higher in the ischemic ECG change group despite of optimal medical therapy. Conclusions The patients with ischemic ECG changes during Ach provocation tests were associated with more frequent chest pain, baseline spasm, diffuse, severe and multi-vessel spasm than patients without ischemic ECG changes. At 5-years, the incidences of death, MACE and MACCE were higher in the ischemic ECG change group, suggesting more intensive medical therapy with close clinical follow up will be required.

A Case of Takotsubo Cardiomyopathy Complicated with Life Threatening Arrhythmia and Cardiogenic Shock

Stress (Takotsubo) cardiomyopathy (CM) is defined as a transient regional systolic dysfunction of the left ventricle that mimics acute coronary syndrome (ACS) in the absence of significant coronary artery disease or plaque rupture. This phenomenon commonly occurs in postmenopausal females in the presence of emotional, physical and psychological stressors with excess catecholamine stimulation, resulting in diffuse microvascular spasm and subsequently myocardial stunning. Here we report a 58-year-old postmenopausal female patient with end stage renal disease (ESRD) who was presented to our hospital with a clinical picture suggesting ACS. Shortly after admission she progressed to cardiogenic shock and pulseless electrical activity (PEA) and was diagnosed retrospectively with Takotsubo cardiomyopathy. She was successfully treated with beta-blockers, IV fluids and inotropic agents. Intra-aortic balloon pump (IABP) was considered, however, the patient gradually improved to full recovery with resolution of left ventricular function back to normal.

SAT-214 Satoyoshi Syndrome: A Rare Cause of Premature Ovarian Failure

Introduction: Satoyoshi syndrome is a rare multisystemic disorder characterized by painful muscle spasms, alopecia universalis and diarrhea. Endocrine abnormalities associated with this syndrome include delayed puberty, primary amenorrhea and hypoplastic uterus and ovaries. It was first reported in 1967 in Japan with the majority of the cases affecting the Asian population, but cases in other ethnic groups have also been reported. It is a sporadic disease, with female to male ratio of two to one and mean age of onset of 10 years. The underlying etiology is unknown and is thought to be of an autoimmune nature. Case presentation: We report a case of a 27 year old Asian American female with Satoyoshi syndrome that was diagnosed at age 12, when she started to suffer from diffuse muscle spasms mostly in the neck, jaw, and lower extremities along with diarrhea and loss of hair. She received intravenous immunoglobulins (IVIG) and systemic corticosteroid therapy in the past and is currently on annual Rituximab infusion. She also takes Carbamazepine and Imodium for muscle contractions and diarrhea respectively. She had menarche at age 11 and recalls having one menstrual period only. This was followed by amenorrhea and hot flashes, both resolved after starting estrogen and progesterone therapy. She was also noted to have low bone density for which she takes vitamin D. For the past few years, she has been on Norethindrone acetate therapy and reported regular periods on it. She had normal anti-müllerian hormone level two years ago. On physical examination, she had diffuse muscle contractions most notably in the muscles of mastication. She also had global thinning of the hair without patches of hair loss. Breast examination showed Tanner stage V for breast development and pelvic examination showed Tanner stage IV for pubic hair growth. The remainder of her physical exam was normal. Her latest lab work showed luteinizing hormone level of 7.15 mIU/ml, follicular stimulating hormone of 9.60 mIU/ml and estradiol level of 33.4 pg/ml suggestive of normal ovarian function. Conclusion: Our patient had all the characteristic features of Satoyoshi syndrome except premature ovarian failure which is quite unusual for this syndrome. Fewer than 60 cases have been reported worldwide so far making it a diagnostic challenge.

The Effects of Cerebral Vasospasm on Cerebral Blood Flow and the Effects of Induced Hypertension: A Mathematical Modelling Study

Background: Induced hypertension has been used to promote cerebral blood flow under vasospastic conditions although there is no randomised clinical trial to support its use. We sought to mathematically model the effects of vasospasm on the cerebral blood flow and the effects of induced hypertension. Methods: The Anatomically Detailed Arterial Network (ADAN) model is employed as the anatomical substrate in which the cerebral blood flow is simulated as part of the simulation of the whole body arterial circulation. The pressure drop across the spastic vessel is modelled by inserting a specific constriction model within the corresponding vessel in the ADAN model. We altered the degree of vasospasm, the length of the vasospastic segment, the location of the vasospasm, the pressure (baseline mean arterial pressure [MAP] 90 mm Hg, hypertension MAP 120 mm Hg, hypotension), and the presence of collateral supply. Results: Larger decreases in cerebral flow were seen for diffuse spasm and more severe vasospasm. The presence of collateral supply could maintain cerebral blood flow, but only if the vasospasm did not occur distal to the collateral. Induced hypertension caused an increase in blood flow in all scenarios, but did not normalise blood flow even in the presence of moderate vasospasm (30%). Hypertension in the presence of a complete circle of Willis had a marginally greater effect on the blood flow, but did not normalise flow. Conclusion: Under vasospastic condition, cerebral blood flow varies considerably. Hypertension can raise the blood flow, but it is unable to restore cerebral blood flow to baseline.

Clinical characteristics and long-term prognosis of contemporary patients with vasospastic angina: Ethnic differences detected in an international comparative study

BackgroundPossible ethnic differences in clinical characteristics and long-term prognosis of contemporary patients with vasospastic angina (VSA) remain to be elucidated. Methods and resultsThe Japanese Coronary Spasm Association (JCSA) conducted an international, prospective, and multicenter registry study for VSA patients. A total of 1457 VSA patients (Japanese/Caucasians, 1339/118) were enrolled based on the same diagnostic criteria. Compared with Caucasian patients, Japanese patients were characterized by higher proportions of males (68 vs. 51%) and smoking history (60 vs. 49%). Japanese patients more often had angina especially during the night and early morning hours, compared with Caucasians. Ninety-five percent of Japanese and 84% of Caucasian patients underwent pharmacological provocation test. Importantly, no significant differences in the patterns of coronary spasm were apparent, with diffuse spasm most frequently noted in both ethnicities. The prescription rate of calcium-channel blockers was higher in Japanese (96 vs. 86%), whereas the uses of nitrates (46 vs. 59%), statins (43 vs. 65%), renin-angiotensin-system inhibitors (27 vs. 51%), and β-blockers (10 vs. 24%) were more common in Caucasian patients. Survival rate free from major adverse cardiac events (MACE) was slightly but significantly higher in Japanese than in Caucasians (86.7 vs. 76.6% at 5 years, P < 0.001). Notably, multivariable analysis revealed that the JCSA risk score correlated with MACE rates not only in Japanese but also in Caucasian patients. ConclusionThese results indicate that there are ethnic differences in clinical profiles and long-term prognosis of contemporary VSA patients.

Non-occlusive mesenteric ischemia associated with enteral feeding after esophagectomy for esophageal cancer: report of two cases and review of the literature

BackgroundNon-occlusive mesenteric ischemia (NOMI) is a rare but life-threatening complication of early postoperative enteral feeding. We herein report two patients who developed NOMI during enteral feeding after esophagectomy.Case presentationIn case 1, a 75-year-old man with no medical history was diagnosed with multiple primary cancers of the esophagus, stomach, and kidney. He underwent percutaneous endoscopic gastrostomy tube placement followed by thoracoscopic esophagectomy and cervical esophagostomy placement as the first-stage operation. Gastrostomy feeding was started on postoperative day (POD) 3 with a polymeric formula (ENSURE H®). On POD 7, he developed acute abdominal pain and distension with bloody drainage through the gastrostomy tube. Dynamic computed tomography showed massive hepatic portal venous gas and pneumatosis intestinalis. Angiography showed diffuse spasms in the branches of the superior mesenteric artery. Under a diagnosis of NOMI, we started intra-arterial infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 48.In case 2, a 68-year-old man with diabetes and atrial fibrillation was diagnosed with esophageal cancer. His medical history was significant for pylorus-preserving gastrectomy for gastric cancer and small bowel resection for trauma. He underwent thoracoscopic esophagectomy, open total gastrectomy, colonic reconstruction, and jejunostomy tube placement. Adhesiolysis for abdominal severe adhesions caused by previous operations was difficult. Jejunostomy feeding was started on POD 3 with a polymeric formula (Racol®). On POD 7, he developed persistent diarrhea and cervical anastomotic leakage. On POD 9, he developed acute abdominal pain and distension with bloody drainage through the jejunostomy tube. Dynamic computed tomography showed the same findings as in case 1. Under a diagnosis of NOMI, we started intravenous infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 28.ConclusionsThe causes of feeding-related NOMI may include the use of a high-osmolarity formula, preoperative malnutrition, abdominal adhesiolysis, systemic inflammation after anastomotic leakage, and a medical history of diabetes and atrial fibrillation. NOMI should be considered as a differential diagnosis in patients with these risk factors and clinical features such as acute abdominal pain and distension during enteral feeding.

The multi-vessel and diffuse coronary spasm is a risk factor for persistent angina in patients received anti-angina medication.

Coronary artery spasm (CAS) is known to be a risk factor for cardiovascular events. However, there is limited data whether the multi-vessel and diffuse spasm (MVDS) is related to more adverse clinical outcomes compared to the Non-MVDS. The aim of this study is to evaluate the impact of the MVDS on clinical outcomes during a 3-year clinical follow-up period.A total 2797 patients underwent coronary angiography (CAG) with acetylcholine (ACH) provocation test from Nov 2004 to Oct 2010 were enrolled. It is a single-center, observational, prospective, all-comers registry designed to reflect the “real world” practic. The patients were divided into the 3 groups; the negative spasm (NS) group (n = 1188), the Non-MVDS group (n = 1081), and the MVDS group (n = 528). The incidence of major adverse cardiac events (MACE) and recurrent angina was evaluated up to 3 years. To minimize confounding factors, multivariable Cox-proportional hazards regression analysis was performed.In the 3-year clinical follow-up, the incidence of total death, myocardial infarction, de novo percutaneous coronary intervention (PCI), cerebrovascular accident and MACE were similar among the 3 groups. However, recurrent angina occurred more frequently in the MVDS group than in the NS group (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.27–3.02; P = .002). Recurrence angina between the MVDS group and the Non-MVDS group was not statistically significant (HR, 1.36; 95% CI, 0.91–2.03; P = .129).In this study, although the incidence of major adverse cardiovascular events were not different regardless of spasm type, the MVDS was associated with higher incidence of recurrent chest pain requiring repeat CAG during the 3-year follow-up period, suggesting more intensive optimal medical therapy with close clinical follow up would be necessary for this particular subset of patients.