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Role of coronary artery spasm in ischemic heart disease. Therapeutic implications
Insights
Coronary artery spasm is a distinct condition from variant angina and requires specific diagnostic evidence. Its presence impacts prognosis and treatment in various ischemic heart disease syndromes.
Area of Science:
- Cardiology
- Vascular Medicine
- Diagnostic Imaging
Background:
- Coronary artery spasm is often confused with variant angina, but it can occur in broader ischemic heart disease contexts.
- Accurate diagnosis requires clinical, angiographic, and physiological evidence, not solely symptom presentation.
Purpose of the Study:
- To clarify the definition and diagnostic criteria for coronary artery spasm.
- To differentiate coronary artery spasm from variant angina.
- To explore the role of coronary artery spasm in various ischemic heart disease presentations.
Main Methods:
- Review of clinical presentations, diagnostic criteria, and associations with ischemic heart disease.
- Emphasis on angiographic confirmation of coronary artery caliber changes and ischemia.
- Discussion of potential links to acute myocardial infarction and sudden death.
Main Results:
- Coronary artery spasm diagnosis requires confirmed changes in coronary artery caliber with evidence of ischemia.
- Variant angina with ST elevation at rest suggests probable spasm.
- Spasm is a potential factor in rest angina, unstable angina, variable effort angina, myocardial infarction, and sudden death.
Conclusions:
- Coronary artery spasm is a significant factor in myocardial ischemia, particularly in rest angina.
- The relationship between spasm, myocardial infarction, and thrombosis is complex and under investigation.
- Prognosis is influenced by the severity of underlying coronary atherosclerosis; treatment involves nitrates and calcium antagonists.
Abstract:
The term coronary artery spasm should not be used interchangeably with the specific clinical syndrome "variant angina" since it does occur in other acute and chronic ischemic heart disease syndromes. The term coronary artery spasm should not be applied to patients with ischemic heart disease unless there is clinical, angiographic, and physiologic evidence of its presence. The diagnosis of coronary artery spasm is confirmed by angiography, i.e. change in caliber of the coronary arteries plus evidence of ischemia. Probable diagnosis is in patients who have the syndrome of variant angina, i.e. rest angina associated with ST segment elevation on the electrocardiogram. One can be highly suspicious that the spasm is at work in patients who have rest angina, especially those with unstable angina. One can be suspicious of patients who have variable effort angina or walk-through angina. Coronary artery spasm is a possibility in patients with an acute myocardial infarction or acute re-infarction and is also possible that sudden death in patients with normal coronary arteries can be related to coronary artery spasm. Coronary artery spasm is the usual cause of myocardial ischemia in patients with rest angina without effort angina. This has also commonly been documented in patients with rest and effort angina. There are isolated reports suggesting that patients with effort angina pectoris also develop coronary artery spasm. Coronary artery spasm has been documented to occur in association with acute myocardial infarction. Whether coronary artery spasm is the cause or the result of myocardial infarction has not been determined at this time. However, the recent combined use of intracoronary nitroglycerin and intracoronary streptokinase in patients with acute myocardial infarction has shown reversal of totally obstructed arteries and suggests the relationship between coronary artery disease, coronary artery spasm, and in situ coronary thrombosis. The incidence of sudden death in patients with documented coronary artery spasm is unknown. But, since complete heart block and/or ventricular tachycardia occur during episodes of coronary artery spasm, it is not unreasonable to assume that some patients have died as a result of these rhythm disturbances. The prognosis of patients with coronary artery spasm seems to depend on the presence or absence of severe coronary atherosclerosis, i.e. those with severe disease have a worse prognosis. Current therapy of patients with coronary artery spasm involves the use of nitrates and calcium antagonists.(ABSTRACT TRUNCATED AT 400 WORDS)