Ergonovine Test Research Articles

Coronary Artery Responsiveness to Ergonovine Provocation in Patients Without Vasospatic Angina A Quantitative Coronary Angiography Analysis

Even patients without vasospastic angina show vasoconstriction after intracoronary ergonovine administration. We evaluated the determinants of coronary artery responsiveness to ergonovine in such patients.In 165 patients with no provoked electrocardiographic changes or ischemic chest pain during an intracoronary ergonovine test, total cholesterol, triglycerides (TG), high density lipoprotein cholesterol (HDL), and low density lipoprotein cholesterol (LDL) were correlated with the arterial luminal diameters before and after ergonovine infusion and after nitroglycerin injection by quantitative coronary angiography analysis.The mean and maximal basal tone (ie, percent change between baseline luminal diameter and diameter after nitroglycerin) were 7.0 ± 9.9% and 27.9 ± 10.8%, respectively. The mean and maximal responsiveness to ergonovine (ie, percent change between minimal diameter during ergonovine infusion and diameter after nitroglycerin) were 30.3 ± 13.6% and 52.7 ± 16.0%, respectively. The TG level (r = 0.191, P = 0.016) and TG/HDL ratio (r = 0.182, P = 0.021) were positively correlated with the basal tone, whereas LDL level (r = 0.155, P = 0.048) and LDL/HDL ratio (r = 0.172, P = 0.030) were positively correlated with the responsiveness to ergonovine. By multivariate analysis, LDL level, LDL/HDL ratio, and smoking were independent predictors of more than 50% responsiveness to ergonovine.Serum lipid profile and smoking influence the basal tone and responsiveness to ergonovine of coronary artery in patients without vaospastic angina.

Coronary abnormal response has increased in Japanese patients: Analysis of 17 years’ spasm provocation tests in 2093 cases

Abnormal coronary response on acetylcholine test is observed in patients with early coronary atherosclerosis. We analyzed retrospectively the abnormal response rate during 17 years of spasm provocation tests in 2093 consecutive patients. We performed 2093 spasm provocation tests, consisting of 1198 acetylcholine tests and 895 ergonovine tests, between January 1991 and December 2007. Spasm provocation test was mainly performed in patients with ischemic heart disease. Abnormal response was defined as transient >90% luminal narrowing during spasm provocation tests. We classified these 17 years into two periods: former period from January 1991 to December 2000, and the latter period from January 2001 to December 2007. In the former period, 1300 spasm provocation tests were performed and 793 spasm provocation tests were done in the latter period. The incidences of hypertension, dyslipidemia, and diabetes mellitus were significantly increased in the latter period. The values of total cholesterol, triglycerides, and fasting blood sugar were also significantly increased in the latter period. The frequency of abnormal response in the latter period was significantly higher than that in the former period (46.0% vs. 33.2%, p<0.05). The frequency of abnormal coronary response to acetylcholine in the latter period was significantly higher than that in the former period (60.0% vs. 34.0%, p<0.01), whereas there was no difference concerning abnormal response of ergonovine between the two periods (31.9% vs. 30.7%, ns). In Japanese patients, abnormal coronary response to acetylcholine has increased and coronary endothelial dysfunction is suggested to have progressed.

Abstract 4218: Usefulness of 64-Row Multi-Detector Computed Tomography for the Evaluation of Patients with Variant Angina

Invasive coronary angiography is useful in patients with suspected variant angina to document an episode of coronary artery spasm with provocative test. Previous studies have demonstrated that atherosclerosis is present at the sites of vasospasm. The aim of this study was to clarify the relation between 64-row Multi-detector Computed Tomography (MDCT) findings of coronary artery and vasospasm. A total of 58 patients with suspected variant angina (32 females and 26 males, aged 49 to 87 years, mean 65 ± 9 years) who have no evidence of luminal narrowing in major coronary artery with MDCT and underwent ergonovine test to detect the presence of coronary artery spasm were enrolled in this study. Two patients were excluded because of poor images of MDCT. The criteria of positive ergonovine test was total occlusion or localized occlusive spasm associated with chest pain and ST segment elevation after administration of ergonovine into the left coronary artery. The existence of plaques and calcifications in major coronary artery were evaluated with MDCT. 23 of 56 (41.1%) patients were positive with ergonovine test. 9 of 23 (39.1%) were total occlusion and 14 of 23 (60.9%) were localized spasm. Using MDCT, atherosclerotic lesions were observed at all coronary spasm sites. Among the 33 patients with negative ergonovine test, 7 (21.2%) had no plaques in the coronary artery. Presence of plaques was significant factor for positive ergonovine provocation test (p = 0.03). Patients with positive ergonovine test had coronary artery plaques at the site of coronary spasm sites. Absence of coronary artery plaques with MDCT could rule out variant angina. Correlation between ergonovine provocation test and MDCT findings

Role of Coronary Spasm for a Positive Noninvasive Stress Test Result in Angina Pectoris Patients Without Hemodynamically Significant Coronary Artery Disease

A positive noninvasive stress test result is often considered as a false-positive indicator of coronary artery disease (CAD) when coronary angiography reveals no hemodynamically significant CAD. From January 2001 through December 2004, 5474 patients scheduled to undergo exercise electrocardiogram (ECG) [exercise ECG without imaging or exercise ECG with thallium-201 (201Tl) single photon emission tomography (SPECT)] or dipyridamole 201Tl tomography at our outpatient clinic because of chest oppressive sensation were included in this prospective study. Coronary angiography was performed when a noninvasive test result was positive for ischemia or when ischemic chest pain was suspected. Intracoronary methylergonovine testing was performed when spastic angina was suspected and coronary angiography showed no hemodynamically significant CAD. Noninvasive stress testing was positive in 113 (67%) patients with coronary spasm. Of the 53 patients who had positive exercise ECG (exercise ECG with or without imaging), ST depression was found in 50 patients and ST elevationin in 3 patients. Multivessel spasm was found in 6 (15%), 6 (15%), and 7 (21%) of the patients with a positive result on exercise ECG without imaging, exercise ECG with 201Tl SPECT, and dipyridamole 201Tl SPECT, respectively. There was no significant difference in the results of noninvasive stress testing and the number of vessels with coronary spasm (1-vessel spasm versus multivessel spasm) among these 3 noninvasive stress testing groups. Intracoronary ergonovine testing induced coronary spasm in over 50% of patients who had suspected ischemic chest pain, a positive noninvasive stress test, and no hemodynamically significant CAD.

Variant(Prinzmetal)-Angina mit diffusem Koronarspasmus ohne Koronarsklerose

A 49-year-old man developed, over a period of three years, progressively more frequent nocturnal attacks of angina and palpitations. Exercise electrocardiogram was negative. 24-hour Holter monitoring revealed ventricular extrasystoles and tachycardia with ST segment elevations. The dominant left coronary artery, which was free of atherotic changes, went into diffuse spasm after ergonovine administration, accompanied by angina and ventricular extrasystoles. Registration of spontaneous ischaemia confirmed the diagnosis of variant (Prinzmetal) angina. Administration of twice daily 90 mg diltiazem retard and once daily 120 mg isosorbide dinitrate retard at night ended the spasms and with it the attacks of angina and the arrhythmias. This case illustrates that typical angina and ventricular tachyarrhythmias can be caused by spontaneous coronary spasms, even in the presence of normal exercise ECGs and coronary angiograms. If coronary artery spasms are not detectable by ECG, the ergonovine test may further the diagnosis.

Ergonovine test for coronary artery spasm

We would like to thank Dr Cheng [ [1] Cheng T.O. Ergonovine test for coronary artery spasm. Int J Cardiol. Mar 13 2006; 114 ([Electonic publication ahead of print]): 249https://doi.org/10.1016/j.ijcard.2006.01.003 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar ] for his comments concerning our article [ [2] Coma-Canella I. Castano S. Macias A. Calabuig J. Artaiz M. Ergonovine test in angina with normal coronary arteries. Is it worth doing it?. Int J Cardiol. Feb 15 2006; 107: 200-206 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar ] and for bringing to our attention his previous studies. With respect to the third remark, we did not mention the premedication of patients with atropine because is not a common practice in our country. As regards the fifth remark, we agree that angina following ergonovine administration is not enough for an ergonovine test to be positive, as a painful esophageal spasm may result from ergonovine stimulation. Another cause of ergonovine-induced angina may be microvascular spasm, which is usually accompanied by ST-segment elevation in the absence of epicardial coronary spasm [ 3 Nagai H. Nakamura Y. Takata S. Kobayashi K. Angina pectoris associated with ST segment elevation in the absence of epicardial coronary arterial obstruction. Case reports. Angiology. 1994; 45: 391-397 Crossref PubMed Scopus (14) Google Scholar , 4 Horimoto M. Igarashi K. Takenaka T. Inoue H. Yamazaki K. Sakuragi H. Acetylcholine- and ergonovine-induced coronary microvascular spasm reflected by increased coronary vascular resistance and myocardial lactate production. Clin Cardiol. 2000; 23: 221-225 Crossref PubMed Scopus (12) Google Scholar ]. Although the three criteria – typical angina, a focal spasm and ST-segment elevation – must be met for the test to be positive, this is not the case if we prevent their appearance. In fact, some of our patients had a clear angiographic spasm without pain or ST elevation, due to the rapid administration of intracoronary nitroglycerin. The usual order of appearance is: first spasm, second ST-segment elevation and third angina. ST elevation and pain would have appeared in all our patients if we had waited for some time before giving nitroglycerin.

Ergonovine test for coronary artery spasm

I concur wholeheartedly with Coma-Canella et al. [1] that ergonovine test is very worthwhile in diagnosing coronary artery spasm (CAS). However, I would like to make several comments in the following. First, although CAS typically occurs in diseased coronary arteries as in Prinzmetal’s variant angina [2], it may also occur in normal coronary arteries, the so-called Fvariant of the variant_ [3]. In as many as 75% of patients referred for study with the diagnosis of variant angina [4]. Second, whereas exercise test is usually very useful in diagnosing typical angina pectoris, exercise test is usually negative in CAS [5]. Third, the only certain method of diagnosing CAS is by selective coronary arteriography. However, angiographic observations of CAS during routine studies in the cardiac catheterization laboratories are rare, and usually made by chance except when contrast injections are performed during an episode of variant angina. The incidence of CAS observed during routine coronary arteriographic studies is low, because of: (1) the frequent occurrence of Fbenign_ catheter-induced spasm, especially of the right coronary artery; (2) the common practice of premedicating patients with atropine which tends to mask CAS [6]; (3) the routine use of sublingual nitroglycerine for repeated left ventriculography preceding coronary arteriography; (4) delay in exchanging a preformed coronary catheter when the coronary artery in spasm is not the one for which the catheter is designed; (5) concern over repeated injections of the spastic coronary artery during angina with alarming ECG changes and reflex reaction of prompt nitroglycerine administration; (6) the relatively small statistical chance of occurrence at angiography of transient CAS in a sedated

Coronary vasospasm-induced acute coronary syndrome complicated by life-threatening cardiac arrhythmias in patients without hemodynamically significant coronary artery disease

Background Coronary vasospasm-induced electrical and mechanical complications in patients with acute coronary syndrome and no hemodynamically significant coronary artery disease are rarely reported. Methods A total of 733 consecutive patients with acute coronary syndrome admitted to our hospital who subsequently underwent coronary angiography at our institution were enrolled. Patients who had documented complete atrioventricular block or ventricular fibrillation, no evidence of hemodynamically significant coronary artery disease on coronary angiogram, and no other (non-coronary) cardiac abnormalities were included. Patients were followed for subsequent cardiac events and mortality. Results Over a 6-year period at our institution, acute coronary syndrome complicated by life-threatening cardiac arrhythmias developed in six patients who had no hemodynamically significant coronary artery disease with corresponding intra-coronary ergonovine provocative coronary vasospasm. Acute myocardial infarction was diagnosed in five of these patients and variant angina pectoris in one. Complete atrioventricular block was the most common complication in these cases, followed by cardiogenic shock with or without right ventricular infarction, ventricular fibrillation, and severe sinus arrest. These complications were corrected with intravenous fluid, intravenous atropine or cardiac defibrillation. During a median follow-up period of 26 months, none of the patients expired or suffered nonfatal reinfarction. Two individuals who did not stop smoking during follow-up developed recurrent angina after self-discontinuation of calcium antagonists. Conclusions Coronary vasospasm can be a cause of life-threatening cardiac arrhythmias in patients with acute coronary syndrome and no hemodynamically significant coronary artery disease. Coronary angiography with/without intra-coronary ergonovine testing is necessary in acute coronary syndrome patients to identify the underlying pathology and establish appropriate treatment in these cases.

Inflammation: A possible pathogenic link to cardiac syndrome X

Cardiac syndrome X is defined as a typical angina pectoris, positive treadmill exercise test, negative intravenous ergonovine test and normal coronary angiography. The pathogenesis of cardiac syndrome X has previously ascribed to myocardial ischemia that may be caused by microvascular dysfunction and increased sensitivity to intracardiac pain. Despite the extensive studies, the pathophysiological mechanisms in cardiac syndrome, however, remain unclear. More recently, the data has been suggested that chronic inflammation has been associated with cardiac syndrome X. The evidence for the hypotheses included that inflammatory marker are increased, and associated with the disease activity in patients with cardiac syndrome X. And also, statin, a lipid-lowering as well as anti-inflammatory drug, has significantly modified the disease process in this special syndrome. Despite the good prognosis of cardiac syndrome X, the chronic, frequent nature of the persistent angina and reduced exercise tolerance can significantly impair quality of life. Thus, lowering inflammatory response by, for example, use of statin and/or aspirin, might improve coronary microvascular dysfunction. Whether this is a valid approach, however, is still unknown and deserves further investigation. Indeed, as mediators of inflammation are multiple, the strategy of identifying triggers and mechanisms of inflammation in each special clinical setting and directing treatment at the special triggers or to rate limiting steps in effector pathways appears more reasonable or a promising strategy.

Ergonovine test in angina with normal coronary arteries. Is it worth doing it?

Background Patients with angina and normal coronary arteries are often misdiagnosed with having non-cardiac pain. Although vasospasm is a well-known entity, spasm provocation is not routinely done in the majority of hospitals at present. Materials and methods One hundred and sixty two consecutive patients with thoracic pain and normal coronary arteries were retrospectively studied. The characteristics of pain were analysed. One hundred and sixty one non-invasive tests (with and without imaging) were done to 126 patients before angiography. Increasing doses of ergonovine (from 1 to 30 μg) were injected into the coronary arteries to provoke coronary spasm. The correlation between ergonovine-induced spasm and non-invasive tests was studied. Results Oppressive thoracic pain suggestive of angina was present in 144 patients. It occurred at rest in 59 patients, only at night in 14, with effort in 40, and it was mixed in 31. Non-oppressive atypical pain was reported by 18 patients. Non-invasive tests were 94 positive, 60 negative and 7 non-diagnostic. Ergonovine test elicited coronary spasm in 85 patients (52.5%). No significant correlation was found between the positivity of a non-invasive test and ergonovine-induced spasm. Conclusions More than half of the patients with angina and normal coronary arteries can be diagnosed with vasospastic angina if ergonovine test is performed. Even patients with a negative non-invasive test maybe sent to coronary angiography when vasospastic angina is suspected, in order to have an accurate diagnosis.

Spontaneous Coronary Artery Dissection Manifested during Ergonovine Test and Treated with Intravascular Ultrasound Guided Stenting: A Case Report

Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute myocardial ischemia, which frequently presents as sudden death. The pathophysiology and treatment of SCAD have not been fully determined. Herein, a case of SCAD, manifesting as variant angina, which rapidly progressed during an ergonovine test, in which 3 drug-eluting stents were deployed using intravascular an ultrasound guidance, with an excellent immediate result, is reported. (Korean Circulation J 2005;35:264-268)

Need for Documentation of Guidelines for Coronary Artery Spasm An Investigation by Questionnaire in Japan

Because there are no guidelines concerning coronary spasm in Japan, the present study examined the current status of the spasm provocation test. Questionnaires concerning the number of cases of coronary angiography, percutaneous coronary intervention, and invasive/non-invasive spasm provocation tests over 3 years (2001-2003) and the status of spasm provocation tests were sent to members of the Japanese Circulation Society in 120 cardiology hospitals in the Chugoku and Shikoku areas. Completed surveys were returned from 45 hospitals, giving a collection rate of 38%. As a spasm provocation agent, acetylcholine tests were performed in 29 hospitals, and ergonovine tests in 18 hospitals. Non-invasive spasm provocation tests were performed in only 9 hospitals (20%). In total, 5,267 patients underwent acetylcholine spasm provocation test (2,387 patients) or ergonovine spasm provocation test (2,880 patients) and vasospastic angina was diagnosed in 1,663 (2.4%) patients. Invasive spasm provocation tests were performed in 7.8% of patients with diagnostic catheterization and the spasm-positive rate was 31.6%. The difference among hospitals concerning the number of invasive spasm provocation tests was remarkable, and the angiographic spasm-positive standard and acetylcholine/ergonovine dose varied among the hospitals. Guidelines on coronary spasm in Japan are essential to overcome the current differences between institutions.

Relationship Between Serum Lipoprotein(a) Concentrations and Coronary Vasomotion in Coronary Spastic Angina

Elevated lipoprotein(a) (Lp(a)) concentrations are reported to impair endothelium-dependent vasodilatation of the epicardial coronary artery. However, the effects on vasomotor abnormalities in coronary spastic angina (CSA) have not been thoroughly investigated. In the present study 80 sites of spasm (spastic sites) without significant organic stenosis (% diameter stenosis <50%) were assessed in 80 patients with CSA diagnosed by intracoronary ergonovine (EM) test. Spastic sites were divided into 2 groups: Group 1 included 30 sites provoked by the full dose (=50 microg) of EM, and Group 2 included 50 sites provoked with less than 50 microg (34.7+/-8.2 microg). Control subjects (n=22) did not show coronary spasm with the EM test. Serum Lp(a) concentrations were measured in all patients. Group 2 had a significantly greater basal coronary artery tone in the spastic sites than Group 1 (p<0.001). Lp(a) level in Group 2 was significantly higher compared with both the control group and Group 1 (p<0.05 by analysis of variance). Multivariate analysis confirmed that only serum Lp(a) concentration was associated with low-dose EM spasm provocation. Serum Lp(a) concentration could be a marker for high disease activity in CSA.

Exercise-induced left bundle branch block accompanied by chest pain: Correlation with coronary artery disease

A case of a 25-year-old woman with familiar hypercholesterolemia, who was admitted complaining for chest pain on exertion, is presented. She underwent a treadmill stress test and during the exercise left bundle branch block with concomitant chest pain in low heart rate (105/min) was demonstrated. After these findings TL-201 scintigraphy with dipyridamole infusion was performed: Chest pain and left bundle branch block appeared again during the test, and the stress TL-201 tomographic images showed reversible defect in the anterior wall. Finally, the young woman underwent coronary arteriography, which showed normal coronary vessels. The ergonovine test for coronary spasm was negative.

Chest pain after coronary artery stent implantation

A sizeable proportion of patients who undergo successful coronary artery stent implantation experiences chest pain immediately after the procedure and/or in the following months in the absence of in-stent restenosis. We investigated this phenomenon in 57 consecutive patients with stable angina who underwent successful stent implantation. Chest pain characteristics were assessed before stent implantation and during 6-month follow-up. All patients underwent coronary angiography within 6 months of the procedure 48 hours after exercise thallium-201 perfusion scintigraphy. Patients who did not exhibit in-stent restenosis underwent an ergonovine test at the end of routine coronary angiography. During follow-up, 15 patients complained of chest pain. Six of these patients exhibited scintigraphic evidence of myocardial ischemia and in-stent restenosis at angiography. In the remaining 9 patients, chest pain occurred in the absence of in-stent restenosis at angiography. In 8 of these patients intracoronary ergonovine administration reproduced their habitual pain, whereas it did not cause any pain in the 42 patients who were completely asymptomatic at follow-up and without in-stent restenosis. Ergonovine caused more intense vasoconstriction and nitroglycerin caused more intense vasodilation of the reference coronary diameter in patients with than in patients without ergonovine-induced pain (−17 ± 3 vs −9 ± 3%, p <0.001; 9 ± 6 vs 5 ± 4%, p <0.02, respectively). In conclusion, chest pain with features similar to habitual angina occurs in the absence of in-stent restenosis in 1/5 of patients after stent implantation and appears to be associated with more intense coronary vasoreactivity.

Edema agudo de pulmón con coronarias normales: identificación del mecanismo con ecocardiografía con ergonovina

Coronary spasm is a constriction of the epicardial coronary arteries that produces myocardial ischemia. It is considered the main mechanism of the dynamic coronary artery stenosis. The standard method for diagnosing coronary spasm is the ergonovine test during diagnostic coronary angiography. Another test currently used is stress echocardiography with intravenous ergonovine injection. We present the case of a patient with angina, acute pulmonary edema and normal angiographic coronary arteries in which stress echocardiography with ergonovine demonstrated transient severe mitral regurgitation.

Efficiency of ergonovine echocardiography in detecting angiographically assessed coronary vasospasm

Coronary vasospasm plays a major role in provoking myocardial ischemia in patients with variant angina, but also in some patients with acute coronary syndrome including unstable angina, myocardial infarction, and sudden death. Ergonovine provocation has been used for >20 years for detection of coronary artery spasm. 1 Maseri A. L.’Abbate A. Pesola A. Ballestra A. Marzilli M. Maltinti G. Severi S. De Ness D.M. Parodi O. Biagini A. Coronary vasospasm in angina pectoris. Lancet. 1977; 1: 713-717 Abstract PubMed Scopus (153) Google Scholar , 2 Schroeder J.S. Bolen J.L. Wuint R.A. Clark D.A. Hayden W.G. Higgins C.B. Wexler L. Provocation of coronary spasm with ergonovine maleate. New test with results in 57 patients undergoing coronary arteriography. Am J Cardiol. 1977; 40: 487-491 Abstract Full Text PDF PubMed Scopus (226) Google Scholar , 3 Heupler F.A. Proudfit W.L. Razavi M. Shirey E.K. Greenstreet R. Sheldon W.C. Ergonovine maleate provocative test for coronary arterial spasm. Am J Cardiol. 1978; 41: 631-640 Abstract Full Text PDF PubMed Scopus (270) Google Scholar Most data on ergonovine testing have been reported in the preselected group of patients with variant angina, establishing ergonovine as a test of high diagnostic confidence. 4 Bott-Silverman C. Heupler F.A. Yiannikis J. Variant angina comparison of patients with and without fixed severe coronary artery disease. Am J Cardiol. 1984; 54: 1173-1175 Abstract Full Text PDF PubMed Scopus (19) Google Scholar , 5 Bory M. Pierron F. Panagides J. Bonnet J.L. Yvorra S. Desfossez L. Coronary artery spasm in patients with normal or near-normal coronary arteries. Long-term follow-up of 277 patients. Eur Heart J. 1996; 17: 1015-1021 Crossref PubMed Scopus (157) Google Scholar In current clinical practice, when a marked decline in the use of ergonovine testing in the catheterization laboratory is observed, 6 Song J.K. Park S.W. Kang D.H. Hong M.K. Kim J.J. Lee C.W. Park S.J. Safety and clinical impact of ergonovine stress echocardiography for diagnosis of coronary vasospasm. J Am Coll Cardiol. 2000; 35: 1850-1856 Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar accompanied by promising reports on ergonovine echocardiography, a question remains on the incidence, safety, and usefulness of provocative testing for coronary vasospasm in patients with chest pain syndrome and nonsignificant coronary artery stenosis. Thus, the objectives of our study were to evaluate (1) the incidence of angiographically assessed coronary vasospasm in a consecutive population of patients with nonsignificant coronary artery disease, (2) the efficiency of simultaneously performed ergonovine echocardiography in identifying coronary vasospasm, and (3) the relation between ergonovine echocardiographic and angiographic results.

Diagnostic Significance of ECG Ergonovine Provocation Test in Patients with Vasospastic Angina

Background:The diagnostic significance of ECG ergonovine test and the incidence of vasospastic angina in patients with chest pain are still uncertain. Methods:From May 1998 to June 1999, 133 consecutive patients with chest pain were admitted for diagnostic coronary angiography. ECG ergonovine provocation tests were performed in 64 patients who have a clinical history suggesting vasospatic angina, including 27 of 28 patients with vasospastic angina documented electrocardiographically, or who’s coronary angiographic findings could not be explained by their clinical history. Ergonovine was administered intravenously in incremental dose of 0.05, 0.1, 0.2, 0.3, 0.4 mg up to total cumulative dosage of 1.0 mg during coronary angiography (41 cases), in the exercise laboratory (21 cases) or both (2 cases). Results:Of 133 patients with chest pain, vasospastic angina was documented in 32 (24%), unstable angina in 52 (34%), stable angina in 10 (8%), and others in 39 (29%). Angiography demonstrated coronary spasm in 4 additional patients as well as 22 patients with vasospastic angina documented electrocardiographically, but ergonovine tests in the exercise laboratory showed positive response in 5 of 6 patients with vasospastic angina documented. Among the 25 patients with coronary spasm proved angiographically during ergonovine test, ECG findings at the time of coronary spasm were ST segment elevation in 21 (84%), depression in 1 (4%) and no change in 3 (12%) patients, who had branch vessel spasm, 3 vessel spasm or incomplete spasm on coronary angiogram. Of the 31 patients with vasospastic angina who underwent ergonovine tests, positive response occurred in 24 (77%) after a cumulative dose of ≤0.4 mg and in additional 3 (10%) after the higher dose of >0.4 mg. However the other 4 (13%) had no ECG changes even after the higher dose (>0.4 mg) of ergonovine. Conclusion:This results suggest that vasospastic angina appear to be a common cause of chest pain, and ECG ergonovine test with high dose can improve diagnostic sensitivity but cannot detect some patients with vasospastic angina. (Korean Circulation J 2000;30(11):1366-1375)

Antianginal and anti‐ischemic effects of nisoldipine and ramipril in patients with syndrome X

Syndrome X is defined as typical angina pectoris, positive treadmill exercise test, negative intravenous ergonovine test, and angiographically normal coronary arteries. In the present study, we investigated the anti-ischemic and antianginal effects of nisoldipine and ramipril in patients with syndrome X. After 2 weeks of the first wash-out period, 18 patients (7 men, 11 women, age 46 +/- 10 years) were given nisoldipine (NIS) 5 mg twice daily for 4 weeks, and after 2 weeks of the second wash-out period, the same patients were given ramipril (RAM) 2.5 mg once daily for 4 weeks. A treadmill exercise test with modified Bruce protocol was performed at the end of each period. The time to angina in exercise (607 +/- 115 s-650 +/- 117 s, p = 0.006, vs. 630 +/- 114 s-660 +/- 123 s, p = 0.02), total exercise time (612 +/- 110 s-656 +/- 114 s, p = 0.0008, vs. 630 +/- 114 s-660 +/- 123 s, p = 0.02), and maximum MET value (11.09 +/- 2.08-11.86 +/- 2.04, p = 0.0016, vs. 11.42 +/- 2.09-12.2 +/- 2.26, p = 0.01) were increased significantly with both therapy modalities. The time to 1 mm ST-segment depression (123 +/- 93 s-220 +/- 172 s, p = 0.002) was increased significantly with NIS therapy. The time to ST-segment recovery (434 +/- 268 s-330 +/- 233 s, p = 0.016 vs. 443 +/- 289 s-370 +/- 278 s, p = 0.012), the frequency of anginal attacks per week (1.27 +/- 1.4-0 +/- 0.38, p = 0.005, vs. 1 +/- 1.32-0.33 +/- 0.59, p = 0.028), and the need for sublingual nitroglycerin (1.16 +/- 1.29-0.11 +/- 0.32, p = 0.005, vs. 0.94 +/- 1.16-0.27 +/- 0.57, p = 0.012) were decreased significantly with both drugs. We observed that 10 mg daily NIS and 2.5 mg daily RAM have similar anti-ischemic and antianginal effects in patients with syndrome X.

Outcome of Surgical Angioplasty for Isolated Coronary Ostial Stenosis

Background:Although surgical angioplasty for isolated coronary ostial stenosis is assumed as an alternative approach to CABG, the clinical features of isolated coronary ostial stenosis, postoperative complications and follow-up angiographic results would have not been well studied. Methods:We retrospectively studied 24 patients (female:male=20:4, mean age 50.0±12.3 yr) who underwent surgical angioplasty for isolated coronary ostial stenosis using patch (22 fresh autologous pericardium, 2 saphenous vein) during the period of March 1990 through February 1998. Repeat coronary angiography (16 patients) and echocardiography (24 patients) were performed. Aortic regurgitation was evaluated semiquantitatively (Grade I-Grade IV). Results:There were 3 deaths after surgical angioplasty. One death was due to acute coronary dissection perioperatively, the second due to low cardiac output syndrome 2 weeks post-surgery, and the third due to traumatic panperitonitis 10 months post-procedure. Angina recurred in 4 patients and the remaning 18 patients were symptom-free. Repeat angiography (19.3±20.7 Mo) showed widely patent ostium with excellent run-off except 2 patients (1 distal patch stenosis, 1 ostial restenosis in Takayasu’s arteritis). The third symptomatic patient was proven to have coronary spasm by ergonovine test. AR increased in the fourth patient (Grade II → III with patent ostium. Conclusion:Surgical angioplasty may be feasible and alternative operative method to CABG for isolated coronary ostial stenosis. It should however be noted that postop AR can develop and/or increase. Further investigation is needed to evaluate the clinical significance of the AR. (Korean Circulation J 1999;29(1):46-54)