Multivessel Spasm Research Articles

Vasospastic Angina: The Journey to Understanding and Easy Management

Vasospastic angina (VSA), initially described by Prinzmetal as a form of angina occurring at rest, in the second part of the night and associated with transient changes in repolarization such as ST segment elevation on the electrocardiogram. The phenomenon of coronary spasm can occur in patients with or without coronary atherosclerosis. It can be focal or diffuse in one or more epicardial arteries. Its incidence is unknown and highly dependent on the population studied, with higher rates in Asian populations. Several pathophysiological mechanisms have been put forward to explain its occurrence, in particular endothelial dysfunction and hyperreactivity of smooth muscle cells related to damage to Rhokinase. Increased sympathetic nerve activity at night has shown to be involved in the mechanism underlying multivessel coronary spasm and predisposing genetic factors. Diagnosis can be easily establish using Coronary Artery Vasospastic Disorders Summit diagnostic criteria for vasospastic angina; adapted from Beltrame et al. VSA is one of the main aetiologies of MINOCA as stipulated in the last guidelines of ESC on ACS. Management of vasospastic angina is well codified based on lifestyle changes, established pharmacological therapies, control of risk factors, avoidance of triggering factors and possibly the use of percutaneous coronary intervention in cases of associated obstructive coronary artery disease, or an automatic implantable defibrillator.

Takotsubo Syndrome and Coronary Artery Disease: Which Came First-The Chicken or the Egg?

Takotsubo syndrome (TTS) is a clinical condition characterized by temporary regional wall motion anomalies and dysfunction that extend beyond a single epicardial vascular distribution. Various pathophysiological mechanisms, including inflammation, microvascular dysfunction, direct catecholamine toxicity, metabolic changes, sympathetic overdrive-mediated multi-vessel epicardial spasms, and transitory ischemia may cause the observed reversible myocardial stunning. Despite the fact that TTS usually has an acute coronary syndrome-like pattern of presentation, the absence of culprit atherosclerotic coronary artery disease is often reported at coronary angiography. However, the idea that coronary artery disease (CAD) and TTS conditions are mutually exclusive has been cast into doubt by numerous recent studies suggesting that CAD may coexist in many TTS patients, with significant clinical and prognostic repercussions. Whether the relationship between CAD and TTS is a mere coincidence or a bidirectional cause-and-effect is still up for debate, and misdiagnosis of the two disorders could lead to improper patient treatment with unfavourable outcomes. Therefore, this review seeks to provide a profound understanding of the relationship between CAD and TTS by analyzing potential common underlying pathways, addressing challenges in differential diagnosis, and discussing medical and procedural techniques to treat these conditions appropriately.

Updates on Prognostication of Takotsubo Cardiomyopathy: A Literature Review

Abstract Takotsubo cardiomyopathy (TTC), commonly known as “broken heart syndrome” or “stress cardiomyopathy,” is characterized by transient left ventricular (LV) systolic dysfunction, usually in the absence of significant obstructive coronary artery stenosis. The pathophysiology of TTC remains elusive; however, the three most common plausible mechanisms include catecholamine surge causing myocardial stunning, multivessel coronary spasm, and microvascular dysfunction. Although initially thought to be a benign, reversible, and transient disorder, newer research data demonstrate that TTC may sometimes have severe short-term complications and some long-term residual effects. Several risk factors have been associated with the outcomes of TTC. In this review, we aim to provide a comprehensive review of the prognostication of TTC in the context of different clinical variables presented in multiple research studies. Various clinical factors, including the types of TTC triggers, the patient’s sex, the presence of cardiogenic shock, atrial arrhythmias, LV tract obstruction, and the presence of certain other clinical comorbidities may significantly impact patient outcomes in TTC patients. A thorough understanding of these factors helps clinicians to better prognosticate the outcome of their patients. Furthermore, early institution of aggressive treatment interventions in the presence of these risk factors may improve the subsequent clinical course.

Gastropericardial fistula complicated by severe multi-vessel coronary spasm.

Gastropericardial fistula complicated by severe multi-vessel coronary spasm.

Which Coronary Artery Should Be Preferred for Starting the Coronary Spasm Provocation Test?

The spasm provocation test (SPT) is a critical test for diagnosing vasospastic angina (VSA). However, the choice of vessel to be preferred for initiating the SPT-the right coronary artery (RCA) or the left coronary artery (LCA)-is unclear. This study aimed to assess SPT results including SPT-related complications while initiating the SPT in the RCA and LCA. We enrolled 225 patients who underwent coronary angiography and SPTs. The SPT was first performed in the RCA in 133 patients (RCA group) and the LCA in 92 patients (LCA group). We defined VSA as >90% narrowing of the coronary artery during the SPT, accompanied by chest pain and/or ST-T changes on the electrocardiogram. When coronary spasm occurs in two or more major coronary arteries, it is referred to as a multivessel spasm (MVS). SPT-related complications comprised atrial fibrillation, ventricular fibrillation, and unstable hemodynamics following catecholamine use. Analyses using propensity score matching (PSM) were performed in 120 patients. No significant differences in the frequencies of VSA and complications were observed between the two groups (RCA: 79% and 19%, respectively; LCA: 85% and 22%, respectively). In both groups, spasms were most frequently provoked in the left anterior descending coronary artery (both p < 0.001) whereas spasms in the left circumflex coronary artery (LCX) were higher in the LCA group than in the RCA group (p = 0.015). Furthermore, no significant difference in the frequency of MVS was observed between both groups (RCA: 50%, LCA: 62%; p = 0.122). After PSM, no significant difference in the frequencies of VSA and complications were observed between the two groups (RCA: 82% and 15%, respectively; LCA: 88% and 18%, respectively). The frequencies of LCX spasms (RCA: 8%, LCA: 23%; p = 0.022) and MVS (RCA: 40%, LCA: 62%; p = 0.020) were higher in the LCA group than in the RCA group. Although the diagnostic rate of VSA and frequency of SPT-related complications were similar in the two groups, the frequency of MVS was higher in the LCA group than in the RCA group because of the increase in the number of LCX spasms. A routine SPT may be started from the LCA.

Acute coronary syndrome due to multi-vessel coronary artery spasm in an Afghan refugee adolescent mimicking recurrent myocarditis.

Vasospastic angina is extremely uncommon for adolescents to experience chest discomfort, which is defined by transitory ST segment elevation or depression and angina symptoms that occur while at rest. It may result in potentially fatal conditions like myocardial infarction, ventricular fibrillation, or even sudden cardiac arrest. To aim of this article is to report a very rare case of a 17-year-old male Afghan refugee who was diagnosed with vasospastic angina after presenting with chest pain, and after receiving calcium channel blocker and nitrates for medical therapy, there were no angina attacks. Our case underlines the value of a thorough evaluation of adolescent's chest pain, the need to diagnose based on the symptoms, and the necessity of performing coronary angiography to rule out coronary causes when there is a high suspicion to a cardiac cause.

Life-Threatening Multivessel Coronary Artery Vasospasm Necessitating Surgical Sympathectomy

Coronary artery vasospasm, particularly multivessel coronary spasm, is an uncommon pathology. There is a paucity of literature to guide clinicians on the management of this clinical entity in the surgical setting. We report a case of a 39-year-old lady who presented with severe multivessel coronary vasospasm that masqueraded as surgical coronary atherosclerotic disease.

Clinical Characteristics and Prognosis of Patients with Vasospastic Angina Subjected to the Spasm Provocation Test and the Unavoidable Use of Nitroglycerin.

Multi-vessel spasm (MVS) has a prognostic impact in patients with vasospastic angina (VSA). Thus, the presence of coronary spasm in both the left coronary artery (LCA) and right coronary artery (RCA) should be assessed through the spasm provocation test (SPT). Nitroglycerin (NTG) is used to avoid SPT-related complications; however, this unavoidable use of NTG may decrease the detection of MVS. Therefore, we investigated the frequency of the unavoidable use of NTG during SPT and clarified the clinical characteristics in patients with VSA who underwent the unavoidable use of NTG during STP. A total of 141 patients with positive SPT were evaluated. A positive SPT was defined as &gt; 90% constriction in epicardial coronary arteries in response to acetylcholine, accompanied by the usual chest symptoms and/or ischaemic ST-T changes on electrocardiography. When a coronary spasm occurred, we usually wait for the spontaneous relief of the coronary spasm. However, if a prolonged coronary spasm or unstable haemodynamics occurred, 0.3 mg NTG was administered intracoronarily to promptly relieve the coronary spasm and this was defined as the unavoidable use of NTG. Even when the unavoidable use of NTG was administered in one coronary artery, an additional SPT was performed on another coronary artery. If a coronary spasm occurred in another coronary artery, a positive SPT was diagnosed. In contrast, if a coronary spasm was not induced after the unavoidable use of NTG, the judgement was classified as undiagnosed. The patients were divided into two groups according to the unavoidable use of NTG: U-NTG (n = 42) and the final use of NTG: F-NTG (n = 99). The clinical characteristics and frequencies of MVS (≥2 major coronary arteries in which a coronary spasm was provoked) and complications (malignant arrhythmia and unstable haemodynamics requiring catecholamines) during the SPT were compared between the groups. Except for smoking status, all other clinical characteristics did not differ significantly between the groups. More current smokers were observed in the U-NTG group (29%) than in the F-NTG group (12%, p = 0.02). The frequency of MVS did not vary significantly between the groups (p = 0.28), with 64% for U-NTG and 55% for F-NTG. No significant difference was found between the groups in the frequency of severe complications during SPT (p = 0.83), with 2% for U-NTG and 3% for F-NTG. In the U-NTG group, the positive induction rate of coronary spasm in another coronary artery was 40% (17/42). Conclusions: The unavoidable use of NTG occurred in ~30% of patients with VSA, most of whom were current smokers. It did not decrease the detection of MVS and potentially prevented severe complications during SPT. Therefore, the unavoidable use of NTG is acceptable during SPT. However, an additional test may need to be performed to assess the presence of MVS.

1094 MULTIVESSEL CORONARY ARTERY SPASM TRIGGERED BY GANGLIONATED PLEXI STIMULATION DURING ATRIAL FIBRILLATION RADIOFREQUENCY CATHETER ABLATYION: A CASE REPORT

Abstract Background Atrial fibrillation is the most common sustained cardiac arrhythmia in adults and it is associated with a high burden of mortality and morbidity worldwide. Atrial fibrillation could be managed with rate-control or rhythm-control strategies. The latter is increasingly used to improve symptoms and prognosis in selected patients, especially after the development of catheter ablation. Although this technique is generally considered safe, it is not free from rare but life-threatening procedure-related adverse events. Among these, coronary artery spasm is an uncommon but potentially fatal complication that requires immediate diagnosis and treatment. Case summary We report a case of severe multivessel coronary artery spasm triggered by ganglionated plexi stimulation during pulmonary vein isolation with radiofrequency catheter ablation in a patient with persistent atrial fibrillation, promptly resolved after intracoronary nitrate administration. Discussion Although rare, coronary artery spasm is a serious complication of atrial fibrillation catheter ablation. Immediate invasive coronary angiography is key for both diagnosis confirmation and treatment of such dangerous condition. As the number of invasive procedures increases, it is important that both interventional and general cardiologists are aware of possible procedure-related adverse events.

Sex Difference in Coronary Artery Spasm Tested by Intracoronary Acetylcholine Provocation Test in Patients with Nonobstructive Coronary Artery Disease.

Introduction Cardiovascular diseases manifest differently in men and women. The purpose of this study is to compare the sex difference in the characteristics of coronary artery spasm (CAS) in patients with nonobstructive cardiovascular disease (NOCVD) and the clinical outcomes in accordance with sex in CAS patients. Methods The study analysed 5,491 patients with NOCVD who underwent an acetylcholine provocation test from November 2004 to May 2014 for evaluation of chest pain. CAS was defined as greater than 70% of luminal narrowing of the artery during the acetylcholine provocation test. Results The patients were divided into men (n = 2,506) and women (n = 2,985). Mean follow-up days were 1,218 ± 577 days. To adjust for confounding factors, the propensity score matching (PSM) analysis was performed in all patients and among the CAS patients. After PSM analysis, a total of 1,201 pairs in all patients and a total of 713 pairs in CAS patients were generated. In all patients, women showed significantly less incidence of CAS compared with men (62.3% vs 50.9%, P < 0.01). Myocardial bridge (MB) and moderate stenosis were less prevalent in women, while transient ST elevation and ischemic chest pain during provocation were more frequent in women. In CAS patients, men had a higher incidence of multivessel spasm than women (35.7% vs. 29.7%, P < 0.01). Old age, dyslipidemia, and MB were independent risk factors of CAS in both men and women. In CAS patients, there was no statistical differences for various individual and composite major outcomes up to five years in either men or women. In men with CAS, old age was a risk factor of a 5-year major adverse cardiac event (MACE), and moderate stenosis was a risk factor of both 5-year MACE and 5-year recurrent angina. In women with CAS, mild stenosis was a risk factor of 5-year MACE, while myocardial bridge was a risk factor of 5-year recurrent angina. Conclusions In this study, there were sex differences in the angiographic and clinical parameters during the acetylcholine provocation test, incidence of CAS, risk factors of CAS, 5-year MACE, and recurrent angina. Old age, dyslipidemia, and MB were independent risk factors of CAS in both sexes. However, major clinical outcomes up to five years in CAS patients were not different according to sex.

Epicardial mapping complicated by multi-vessel coronary spasm and electrical storm.

The case report describes a severe multi-vessel coronary spasm complicating the epicardial mapping in a patient with chronic Chagas cardiomyopathy.

Clinical Characteristics and Prognosis of Patients with Multi-Vessel Coronary Spasm in Comparison with Those in Patients with Single-Vessel Coronary Spasm.

(1) Background: We have sometimes experienced patients with vasospastic angina (VSA) who presented multi-vessel spasm (MVS) on coronary angiography and spasm provocation test (SPT). However, the clinical characteristics of VSA patients with MVS and the prognosis of such patients in the clinical setting have not been clarified. Therefore, we compared the clinical characteristics and prognosis in VSA patients with MVS with those in VSA patients with single-vessel spasm (SVS). (2) Methods: A total of 152 patients (mean age, 67 years, 74 men and 78 women) with VSA, in which the presence of coronary spasm was assessed in both left coronary artery (LCA) and right coronary artery (RCA) on SPT, were enrolled. We defined VSA as the presence of >90% narrowing of the epicardial coronary artery on angiograms, accompanied by usual chest symptoms and/or ischaemic ST-T changes on the electrocardiogram. On SPT, MVS was defined as the presence of spasms on ≥2 major coronary arteries. Based on the presence of MVS, patients were divided into the MVS group and the SVS group. The frequencies of conventional coronary risk factors, blood chemical parameters, average times of anginal attack, SPT findings such as spasm provocation induced by a low dose of acetylcholine (L-ACh) and total occlusion due to coronary spasm (TOC), number of coronary vasodilators at discharge and major cardiovascular events (MACE, including cardiac death and readmission due to any cause of cardiovascular diseases) were compared between the two groups. (3) Results: The MVS and SVS groups were comprised of 98 (64%) and 54 (36%) patients, respectively. The level of fasting blood glucose (FBS) was lower (p < 0.01), and the level of cystatin-C (n = 89) tended to be higher (p = 0.07) in the MVS group than in the SVS group. The frequencies of L-ACh-induced coronary spasm (33% in MVS and 17% in SVS, p = 0.04) and TOC (12% in MVS, 0% in SVS, p < 0.01) were higher in the MVS group than in the SVS group. The average number of coronary vasodilators at discharge was higher in the MVS group (1.2 ± 0.4) than in the SVS group (0.9 ± 0.5, p < 0.01). The frequency of MACE was not different between the two groups. (4) Conclusions: Patients with MVS may have higher VSA activity on SPT and have more aggressive medications, leading to a comparable prognosis in VSA patients with SVS. MVS is an important indicator of at least VSA activity, and cardiologists should confirm this in SPT whenever possible. Further studies should confirm whether lower FBS levels and higher cystatin-C levels are any markers of MVS.

MALIGNANT MULTI-VESSEL CORONARY ARTERY SPASM; A RARE CAUSE OF MYOCARDIAL INFARCTION LEADING TO CARDIOGENIC SHOCK – A CASE REPORT

Malignant multi-vessel coronary vasospasm is a rare life threatening condition, presentation like myocardial infarction (MI), arrhythmias, and cardiogenic shock (CS). We report a case of IWMI complicated by CS, angiogram shows diffuse multi-vessel coronary artery spasm. Intracoronary nitroglycerine showing improving spasm in culprit vessel RCA and distal RCA stented with excellent result. This case of early diagnosis of coronary artery spasm to prevent the occurrence of MI, arrhythmias and sudden cardiac death as it is one the rare cause. It also highlighted the role of intracoronary nitroglycerine in relieving diffuse multi-vessel vasospasm in hemodynamically unstable patient.

Five-year follow-up and outcomes of takotsubo/stress cardiomyopathy in a single centre- an irish perspective

Abstract Funding Acknowledgements Type of funding sources: None. Background Takotsubo Cardiomyopathy (TC) is an acute cardiac presentation characterised by acute myocardial injury and transient left ventricular systolic dysfunction, in the absence of obstructive coronary disease(1). Postulated causes include catecholamine excess, microvascular dysfunction, and multi-vessel coronary artery spasm. Predominantly seen in post-menopausal women, frequently triggered by emotional or physical stressor with in-hospital mortality rate reported at 2-5%(2). We present a single centre experience of TC with five-year follow-up. Methods We performed a retrospective descriptive study of patients with a diagnosis of TC coded by Hospital In-Patient Enquiry data from a tertiary level Irish hospital between 2010 and 2016. Data collection was electronic patient records/chart review. 21 cases were confirmed by modified Mayo Clinic criteria(3). Three patients were lost to follow up, two patients died during the follow-up period and one patient was excluded due to a focal area of transmural infarction on follow-up cardiac magnetic-resonance imaging (CMRI). Follow up data was obtained on sixteen patients up to 01/08/2021. Statistical analysis using SPSS v. 27, expressed as mean +- SD in %. Results Mean age at event was 64 +/- 12 years, 95% were female. Triggers identified in 55% of cases; emotional stressors in 35%, physical stressors in 25%. All had raised Troponin I (peak 3.13 ± 2.42ng/ml) and electrocardiograph (ECG) changes. Coronary angiography performed in all with no or mild CAD in seventeen and moderate CAD in two cases. CMRI was performed in 60% (n = 12) at on average 14.8 months post discharge. Average left ventricular ejection fraction (LVEF) was 31+/- 8% and 62+/-7% at diagnosis and follow up respectively, improving in all cases with mean improvement of 30.8 +/-11% (p &amp;lt; 0.001). Three patients had a further TC event. Two of the cases underwent angiography at the time of second presentation with normal coronary arteries and follow-up imaging showed full LVEF recovery in both cases. The third patient is awaiting follow-up CMRI. Of the recurrent cases two occurred despite best medical therapy. Two of the cases showed full recovery of LVEF between events and one showed minimal LVEF improvement prior to recurrence but full recovery after the second event. All patients who remained in Ireland had initial follow up (n = 15), 46% attend Cardiology outpatients in 2021. Conclusions Our demographic data is similar to previous studies with the majority of cases occurring in postmenopausal women(4). Our mortality rate was 9.5%, current published prognostic data in TC are limited and conflicting(2). The recurrence rate among our small cohort was 16.6% (n = 3) despite cardio-protective medications in two of the three cases, higher than previous reviews(5). The time to clinical and imaging follow up was discordant but all patients in our follow up group regained a normal LVEF which is very reassuring and in-keeping with prior studies. Abstract Figure. TTE apical 4-chamber view Abstract Figure. CMRI 4-chamber view end systole

Abstract 12505: Clinical Characteristics of Patients With Vasospastic Angina Subjected to the Spasm Provocation Test Involving the Unavoidable Use of Nitroglycerin

Introduction: Multivessel spasm (MVS) has a prognostic impact in patients with vasospastic angina (VSA). Thus, assessing for the presence of MVS in both left coronary artery and right coronary artery is preferable in the spasm provocation test (SPT). The use of nitroglycerin is necessary to avoid the complications related to SPT; however, this unavoidable use of NTG (U-NTG) may decrease the detection of MVS. Hypothesis: We investigated the frequency of U-NTG during SPT and clarified the clinical characteristics in VSA patients, with U-NTG during STP. Methods: Total 142 patients with positive SPT were evaluated. A positive SPT was defined as &gt;90% constriction in coronary arteries, accompanied by the chest symptoms and/or ischemic ST-T changes. When a coronary spasm occurred, we usually waited for the spontaneous relief of the coronary spasm. However, if a prolonged coronary spasm or unstable hemodynamics occurred, NTG was administered to relieve the coronary spasm promptly (U-NTG). Even when U-NTG was administered in one coronary artery, an additional SPT was performed on another coronary artery. The patients were divided into two groups according to U-NTG: U-NTG(+) (n = 42) and U-NTG(-), (n = 100). The clinical characteristics and frequencies of MVS and complications (unstable hemodynamics) during the SPT were compared between the groups. Results: Except for smoking status, all other clinical characteristics status did not differ significantly between the groups. More current smokers were observed in the U-NTG(+) group (29%) compared with that in the U-NTG(-) group (12%, p = 0.03). The frequency of MVD did not vary significantly between the groups, with 64% in the U-NTG(+) and 52% in the U-NTG(-). No significant difference was found between the groups in the frequency of severe complications during SPT, with 5% in U-NTG(+) and 3% in U-NTG(-). In U-NTG(+), the positive induction of coronary spasm in another coronary artery was 40% (17/42). Conclusions: Our results show that U-NTG occurred in ~30% of VSA patients, especially in current smokers, and that it did not decrease the detection of MVS and prevented severe complications during SPT. Therefore, U-NTG is acceptable during SPT, after which, another test may be performed to assess the presence of MVS.

Abstract 13657: Malignant Multivessel Coronary Spasm

Objective: Management of multivessel coronary spasm is challenging. Case: A 59-year-old female with a medical history of CAD status post coronary stents presented with atypical chest pain.The following morning the patient suffered a PEA arrest, from which she was resuscitated. Retrospective review of telemetry revealed frequent episodes of transient ST segment elevations in inferior leads, lasting minutes, eventually followed by sinus bradycardia and episodes of high-degree AV block with pauses up to 20 seconds.Two weeks earlier the patient presented at another institution with similar complaints. Inferior STEMI was diagnosed, she received 2 DES, in proximal OM1 and Mid LAD. She represented 6 days later with continued symptoms and repeat catheterization revealed patent stents. She was reassured and discharged on Isosorbide Mononitrate in addition to Carvedilol. Management and Decision Making: Coronary angiography at our facility demonstrated 90% stenosis of proximal LCX and 60-70% of proximal LAD. These stenosis resolved with intracoronary nitroglycerin. The stents were patent. Therefore, she was diagnosed with coronary spasm. During her hospital stay, the patient did have four more episodes of ST elevations associated with complete heart block. Since she developed high degree AV block after a coronary spasm, a temporary pacemaker was placed. Norvasc as well as nitroglycerin drip were used to treat her coronary vasospasm. Pure B-blocker medications were avoided to prevent unbalanced alpha effect.The patient was extubated 4 days later and fully recovered neurologically. A permanent pacemaker was placed and discharged home. Conclusion: High suspicion is important for diagnosis of coronary vasospasm. Treatment with coronary vasodilators is cornerstone of management. We also avoided pure alpha agonists during resuscitation measures, as well as pure B-blocker medications after recovery.

Clinical characteristics and prognosis in patients with multi-vessel coronary spasm – comparison with those in patients with single-vessel coronary spasm

Abstract Background We have sometimes experienced patients with vasospastic angina (VSA), who showed multi-vessel spasm (MVS) on coronary angiography (CAG) and spasm provocation test (SPT). However, it has not been clarified what clinical characteristics VSA patients with MVS have or whether such patients have poor prognosis. Therefore, we compared the clinical characteristics and prognosis in VSA patients with MVS with those in VSA patients with single-vessel spasm (SVS). Methods One hundred and fifty-two patients (mean age: 67 yrs, 74 men and 78 women) with VSA, in which presence of coronary spasm was assessed in both left coronary artery (LCA) and right coronary artery (RCA) on SPT, were subjected. We defined VSA as the presence of more than 90% narrowing of the epicardial coronary artery on angiograms, accompanied by the usual chest symptoms and/or ischemic ST-T changes on electrocardiogram. On SPT, MVS was defined as the presence of spasm on ≥ two major coronary arteries. Base on the presence of MVS, patients were divided into the following 2 groups: MVS group and SVS group. The frequencies of conventional coronary risk factors, the average times of anginal attack (per month), the findings of SPT such as spasm provocation induced by low dose of acetylcholine (LDA) and total occlusion due to coronary spasm (TOC), the number of coronary vasodilators at discharge, and the major cardiovascular events (MACE) including death of any cause and readmission due to heart failure, acute coronary syndrome and unstable angina, were compared in the two groups. Results There were 98 patients (64%) in the MVS group and 54 patients (36%) in the SVS groups. The frequencies of conventional coronary risk factors and the average times of anginal attacks (4/month in both groups) were not different in the two groups. The frequencies of LDA (33% in MVS and 17% in SVS, p&amp;lt;0.05) and TOC (12% in MVS, 0% in SVS, p&amp;lt;0.01) were higher in the MVS group than in the SVS group. The average numbers of coronary vasodilators was higher in the MVS group (1.1±0.4) than in the SVS group (0.9±0.4, p&amp;lt;0.01). The frequency of MACE did not differ in the two groups as follows (figure). Conclusions These findings suggest that there was no clinical characteristic, suggesting the presence of MVS in VSA patients. Such patients may have higher VSA activity on SPT and have more aggressive medications, leading to the similar prognosis in VSA patient with SVS. Funding Acknowledgement Type of funding sources: None.

Current Knowledge and Future Challenges in Takotsubo Syndrome: Part 1-Pathophysiology and Diagnosis.

First recognized in 1990, takotsubo syndrome (TTS) constitutes an acute cardiac condition that mimics acute myocardial infarction commonly in the absence of obstructive coronary artery disease; it is characterized by temporary left ventricular dysfunction, regularly in a circumferential apical, midventricular, or basal distribution. Considering its acute clinical presentation, coronary angiography with left ventriculography constitutes the gold standard diagnostic tool to exclude or confirm TTS. Frequently, TTS is related to severe emotional or physical stress and a subsequent increased adrenergic stimulation affecting cardiac function. Beyond clinical presentation, epidemiology, and novel diagnostic biomarkers, this review draws attention to potential pathophysiological mechanisms for the observed reversible myocardial dysfunction such as sympathetic overdrive-mediated multi-vessel epicardial spasms, microvascular dysfunction, the direct toxicity of catecholamines, lipotoxicity, and inflammation. Considering the long-term prognosis, further experimental and clinical research is indispensable to elucidate further pathophysiological mechanisms underlying TTS before randomized control trials with evidence-based therapeutic management can be performed.

When Blades broke my heart.

Takotsubo cardiomyopathy (TCM) was first described about 30 years ago. It has been attributed to the sudden catecholamine surge in relation to severe stress, which can cause multi-vessel coronary spasms and myocardial apical ballooning. Football supporters are prone to develop severe stress due to sudden changes in match results. This case presents a football supporter of Sheffield United (the Blades) who was admitted to the hospital with cardiac sounding chest pain following a last minute goal by the opposing team. The necessary investigations were carried out including coronary angiogram and echocardiogram. He was diagnosed with TCM following a left ventricular angiogram demonstrating the typical appearance of the octopus pot.

Severe multivessel coronary artery spasm detected by computed tomography: a case report.

BackgroundVentricular arrhythmia and sudden cardiac arrest caused by multivessel coronary artery spasm (CAS) is rare. Although coronary angiography (CAG) with provocation testing is the diagnostic gold standard in current vasospastic angina guidelines, it can cause severe procedure-related complications. Here, we report a novel technique involving dual-acquisition coronary computed tomography angiography (CCTA) to detect multivessel CAS in a patient who survived out-of-hospital cardiac arrest (OHCA).Case summaryA 58-year-old healthy Korean male survived OHCA caused by ventricular fibrillation (VF), experiencing seven episodes of defibrillation and cardiopulmonary resuscitation, and was referred to the Emergency Room. Vital signs were stable and physical examination, electrocardiogram, chest, and brain CT did not show any abnormal findings, except elevated hs-Troponin I levels (0.1146 ng/mL). Echocardiogram revealed a regional wall motion abnormality in the inferior wall, with a low normal left ventricular ejection fraction (50%). A multivessel CAS (both left and right) was detected using a dual-acquisition CCTA technique (presence and absence of intravenous nitrate). During CAG with the 2nd injection of ergonovine, a prolonged and refractory total occlusion in the proximal-ostial right coronary artery was completely relieved after a seven-cycle intracoronary injection regimen of nitroglycerine. The patient was discharged with the recommendation of smoking and alcohol cessation. Nitrate and calcium channel blockers were also prescribed. The patient had no further events at 3 months of follow-up after discharge.DiscussionDual-acquisition CCTA is a promising tool to detect multivessel CAS.