Abstract
Background: Recently, several case reports have implicated vasospasm of small coronary arteries in vasospastic angina pectoris. Vasospasm of small coronary arteries was also considered from angiographic findings in patients with atypical chest pain. In Syrian hamster, vasospasm in small coronary arteries was considered to be the cause of dilated cardiomyopathy.
Hypothesis: This study was undertaken to determine whether vasospasm in small coronary arteries can be induced by methylergometrine maleate stress thallium‐201 (201T1) myocardial scintigraphy.
Methods: Twenty‐five patients with chest pain, all of whom had intact coronary arteries, were studied. After intracoronary methylergometrine maleate injection, coronary arteriograms also looked normal in all cases. Thallium‐201 myocardial scintigraphy was carried out immediately after intracoronary methylergometrine maleate injection in four patients with chest pain. In the remaining 21 patients with chest pain, methylergometrine maleate was given intravenously within up to 2 weeks before 201T1 myocardial scintigraphy.
Results: In the intracoronary injection study, one patient had chest discomfort after methylergometrine maleate injection, and ST‐segment elevation was observed on electrocardiogram (ECG). Of the 21 patients with chest pain, 11 patients felt angina‐like chest pain after intravenous injection of methylergometrine maleate, but their ECGs showed no ischemic changes. Stress 201T1 myocardial scintigrams showed methylergometrine maleate‐induced perfusion defects with complete redistribution in 3 of 4 patients in the intracoronary injection study and in 12 of 21 patients in the intravenous injection study. These findings suggest that vasospasm in small coronary arteries caused myocardial ischemia in 15 of 25 patients (60%) with chest pain.
Conclusion: Vasospasm in small coronary arteries may be involved in the myocardial ischemia of some patients with chest pain who do not show any large coronary artery vasospasm.
Keywords: small coronary arteries, vasospasm, methylergometrine maleate, thallium‐201 myocardial scintigraphy
Full Text
The Full Text of this article is available as a PDF (1.2 MB).
References
- 1. Kawakami K, Shimada T, Nakayama K, Nagasaka Y, Tsukihashi H, Murakami R, Morioka S, Moriyama K: Angina pectoris due to possible vasospasm of small coronary arteries. Clin Cardiol 1991: 14: 775–777 [DOI] [PubMed] [Google Scholar]
- 2. Serota H, Kern MJ, Deligonul U, Aguirre F, Caralis DG: Ergonovine‐induced myocardial ischemia without epicardial coronary vasospasm: Evidence for ischemia produced by small‐vessel vasoconstriction. Am Heart J 1991; 121: 1807–1809 [DOI] [PubMed] [Google Scholar]
- 3. Factor SM, Sonnenblick EH: Hypothesis: Is congestive cardiomyopathy caused by a hyperreactive myocardial microcirculation (microvascular spasm)? Am J Cardiol 1982; 50: 1149–1152 [DOI] [PubMed] [Google Scholar]
- 4. Yokoi H, Ichibayashi T, Usuda K, Hirota S, Maeno K, Kubota K, Takada S, Ikeda T: Left ventriculography after ergometrine stress. J Cardiol 1990; 20 (suppl 21): 72 [Google Scholar]
- 5. Cannon RO III, Watson RM, Rosing DR, Epstein SE: Angina caused by reduced vasodilator reserve of the small coronary arteries. J Am Coll Cardiol 1983; 1: 1359–1373 [DOI] [PubMed] [Google Scholar]
- 6. Cannon RO m, Bonow RO, Bacharach SL, Green MV, Rosing DR, Leon MB, Watson RM, Epstein SE: Left ventricular dysfunction in patients with angina pectoris, normal epicardial coronary arteries, and abnormal vasodilator reserve. Circulation 1985; 71: 218–226 [DOI] [PubMed] [Google Scholar]
- 7. Mohri M, Koyanagi M, Egashira K, Tagawa H, Ichiki T, Shimokawa H, Takeshita A: Angina pectoris caused by coronary microvascular spasm. Lancet 1998; 351: 1165–1169 [DOI] [PubMed] [Google Scholar]
- 8. Hackett D, Larkin S, Chierchia S, Davies G, Kaski JC, Maseri A: Induction of coronary artery spasm by direct local action of ergometrine. Circulation 1987; 75: 577–582 [DOI] [PubMed] [Google Scholar]
- 9. Waters D, Szlachcic J, Bonan R, Miller D, Daune F, Théroux P: Comparative sensitivity of exercise, cold pressor and ergometrine testing in provoking attacks of variant angina in patients with active disease. Circulation 1983; 67: 310–315 [DOI] [PubMed] [Google Scholar]
- 10. Borrello JA, Clinthorne NH, Rogers WL, Thrall JH, Keyes JW: Oblique‐angle tomography: A restricting algorithm for transaxial tomographic data. J Nucl Med 1981; 22: 471–473 [PubMed] [Google Scholar]
- 11. Kawakami K, Yasuda I, Shimada T, Murakami R, Morioka S, Moriyama K: Reevaluation of Bullseye map in the patient with coronary heart disease (abstr). Jpn J Nucl Med 1989: 26: 921 (in Japanese) [Google Scholar]
- 12. Kawakami K, Shimada T, Yamada S, Murakami R, Morioka S, Moriyama K: The detection of myocardial ischemia by thallium‐201 myocardial scintigraphy in patients with multiple coronary arterioventricular connections. Clin Cardiol 1991; 14: 975–980 [DOI] [PubMed] [Google Scholar]
- 13. Hoshino A, Takami T, Fujimoto Y, Yamasaki J, Hasegawa J, Kotake H, Mashiba H: Coronary artery tone assessed by the administration of ergometrine maleate and nitrate. J Cardiology 1988; 18: 989–1002 (in Japanese) [PubMed] [Google Scholar]
- 14. Hoshio A, Kotake H, Mashiba H: Significance of coronary artery tone in patients with vasospastic angina. J Am Coll Cardiol 1989; 14: 604–612 [DOI] [PubMed] [Google Scholar]
- 15. Ruwitch JF, Ludbrook PA, Sobel BE: Angina with “normal coronary arteries”: A misnomer. Adv Cardiol 1977; 27: 20–40 [DOI] [PubMed] [Google Scholar]
- 16. Maron BJ, Epstein SE, Roberts WC: Hypertrophic cardiomyopathy and transmural infarction without significant atherosclerosis of the extramural coronary arteries. Am J Cardiol 1979; 43: 1086–1102 [DOI] [PubMed] [Google Scholar]
- 17. Hill RC, Chitwood WR, Bashore TM, Sink JD, Cox JL, Wechsler AS: Coronary flow and regional function before and after supraarterial myotomy for myocardial bridging. Ann Thorac Surg 1980; 31: 176–181 [DOI] [PubMed] [Google Scholar]
- 18. Christie LG Jr, Conti CR: Systemic approach to the evaluation of angina‐like chest pain. Am Heart J 1981; 102: 897–906 [DOI] [PubMed] [Google Scholar]
- 19. Braunwald E: Heart Disease, p. 1048 Philadelphia: W.B. Saunders Co., 1988. [Google Scholar]
- 20. Bernstein LM, Fruin RC, Pacini R: Differentiation of esophageal pain for angina pectoris: Role of esophageal acid perfusion test. Medicine 1962; 41: 143–156 [DOI] [PubMed] [Google Scholar]
- 21. Benjamin SB, Costello DO: Chest pain of esophageal origin. Arch Intern Med 1983; 143: 772–780 [PubMed] [Google Scholar]
- 22. Epstein SE, Gerber LO, Borer JS: Chest wall syndrome—a common cause of unexplained chest pain. J Am Med Assoc 1979; 241: 2793–2797 [DOI] [PubMed] [Google Scholar]
- 23. Bass C, Wade C, Hand D, Jackson G: Patients with angina with normal and near normal coronary arteries: Clinical and psychosocial state 12 months after angiography. Br Med J 1983; 287: 1505–1512 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Likoff W, Segal BL, Kasparian H: Paradox of normal selective coronary arteriograms in patients considered to have unmistakable coronary heart disease. N Engl J Med 1967; 276: 1063–1066 [DOI] [PubMed] [Google Scholar]
- 25. Kemp HG: Left ventricular function in patients with the anginal syndrome and normal coronary arteriograms. Am J Cardiol 1973; 32: 375–382 [DOI] [PubMed] [Google Scholar]
- 26. Legrand V, Hodgson JMcB, Bates ER, Auerson FM, Mancini GBJ, Smith JS, Gross MD, Vogel RA: Abnormal coronary flow reserve and abnormal radionuclide exercise test results in patients with normal coronary angiograms. J Am Coll Cardiol 1985; 6: 1245–1252 [DOI] [PubMed] [Google Scholar]
- 27. Prinzmetal M, Kennamer R, Merliss R, Wada T, Bor N: Angina pectoris I. A variant form of angina pectoris. Am J Med 1959; 27: 375–388 [DOI] [PubMed] [Google Scholar]
- 28. Cheng TO, Bashour T, Kelser GA Jr, Weiss L, Bacos J: Variant angina of Prinzmetal with normal coronary arteriograms. A variant of the variant. Circulation 1973; 47: 476–485 [DOI] [PubMed] [Google Scholar]
- 29. Christian N, Botti RE: Prinzmetal's variant angina pectoris with prolonged electrocardiographic changes in the absence of obstructive coronary artery disease. Am J Sci 1972; 263: 225–234 [DOI] [PubMed] [Google Scholar]
- 30. Dhurandhar RW, Watt DL, Silver MD, Trimble AS, Adelman AG: Prinzmetal's variant form of angina with arteriographic evidence of coronary arterial spasm. Am J Cardiol 1972; 30: 902–905 [DOI] [PubMed] [Google Scholar]
- 31. Oliva PB, Potts DE, Pluss RG: Coronary arterial spasm in Prinzmetal angina. Document by coronary arteriography. N Engl J Med 1973; 288: 745–751 [DOI] [PubMed] [Google Scholar]
- 32. Endo M, Kanda I, Hosoda S, Hayashi H, Hirosawa K, Konno S: Prinzmetal's variant form of angina pectoris. Re‐evaluation of mechanisms. Circulation 1975; 52: 33–37 [DOI] [PubMed] [Google Scholar]
- 33. Gianelly R, Mugler F, Harrison DC: Prinzmetal's variant of angina pectoris with only slight coronary atherosclerosis. Calif Med 1968; 108: 129–131 [PMC free article] [PubMed] [Google Scholar]
- 34. Stein I: Observations on the action of ergometrine on the coronary circulation and its use in me diagnosis of coronary artery insufficiency. Am Heart J 1949; 36: 36–42 [DOI] [PubMed] [Google Scholar]
- 35. Rainzner AE, Chahine RA, Ishimori T, Verani MS, Zacca N, Jamal N, Miller RR, Luchi RJ: Provocation of coronary artery spasm by the cold pressor test. Hemodynamic, arteriographic and quantitative angiographic observations. Circulation 1980; 62: 925–932 [DOI] [PubMed] [Google Scholar]
- 36. Yasue H, Nagao M, Omote S, Takizawa A, Miwa K, Tanaka S: Coronary arterial spasm and Prinzmetal's variant form of angina induced by hyperventilation and Tris‐buffer infusion. Circulation 1978; 58: 56–62 [DOI] [PubMed] [Google Scholar]
- 37. Weiss RJ: Recurrent myocardial infarction caused by cocaine abuse. Am Heart J 1986; 111: 793 [DOI] [PubMed] [Google Scholar]
- 38. Yasue H, Touyama M, Kato H, Tanaka S, Akiyama F: Prinzmetal's variant form of angina as a manifestation of alpha‐adrenergic receptor‐mediated coronary artery spasm: Documentation by coronary arteriography. Am Heart J 1976; 91: 148–155 [DOI] [PubMed] [Google Scholar]
- 39. Yasue H, Touyama M, Shimamoto M, Kato H, Tanaka S, Akiyama F: Role of autonomic nervous system in the pathogenesis of Prinzmetal's variant form of angina. Circulation 1974; 50: 534–539 [DOI] [PubMed] [Google Scholar]
- 40. Torii S, Araki Y, Sagara T, Kakimaru Y, Kanaya H, Naitou K: Provocation of anginal attack by subcutaneous injection of pilocarpine hydrochloride. Heart 1974; 6: 338–346 (in Japanese) [Google Scholar]
- 41. Bove AA, Dewey JD: Effects of serotonin and histamine on proximal and distal coronary vasculature in dogs: Comparison with alpha‐adrenergic stimulation. Am J Cardiol 1983; 52: 1333–1339 [DOI] [PubMed] [Google Scholar]
- 42. Lafia P, Dincer B: Coronary artery catheter‐induced spasm. Cathet Cardiovasc Diagn 1982; 8: 607–615 [DOI] [PubMed] [Google Scholar]
- 43. Master AM, Pordey L, Kohler J: Ergotamine tartrate and the “two‐step” exercise electrocardiogram in functional cardiac disturbances. J Mt Sinai Hosp NY 1948; 15: 161–168 [PubMed] [Google Scholar]
- 44. Brazeau P: The Pharmacologic Basis of Therapeutics, p. 872–878. New York: The MacMillan Co., 1975. [Google Scholar]
- 45. Heupler FA Jr, Proudfit WL, Razavi M, Shirey EK, Greenstreet R, Sheldon WG: Ergonovine maleate provocative test for coronary artery spasm. Am J Cardiol 1978; 41: 631–640 [DOI] [PubMed] [Google Scholar]
- 46. Cipriano PR, Guthaner DF, Orlick AE, Ricci DR, Wexler L, Silverman JF: The effects of ergometrine maleate on coronary arterial size. Circulation 1979; 59: 82–89 [DOI] [PubMed] [Google Scholar]
- 47. Tatsuhara T: Pocket Iyakuhinshu, p. 468 Tokyo: Hakubunsha, 1983. [Google Scholar]
- 48. Richieb JL, Zaret BJ, Straus HW, Ashburn WN, Berger HJ, Hamilton GW: Myocardial imaging with thallium‐201: A multi‐center study in patients with angina pectoris or myocardial infarction. Am J Cardiol 1978; 42: 345–350 [DOI] [PubMed] [Google Scholar]
- 49. Tamaki N, Yonekura Y, Mukai T, Fujita T, Nohara R, Kadota K, Kanbara H, Kawai C, Torizuka K, Ishii Y: Segmental analysis of stress thallium myocardial emission tomography for localization of coronary artery disease. Eur J Nucl Med 1984; 9: 99–105 [DOI] [PubMed] [Google Scholar]
- 50. Maddahi J, Train KV, Wong C, Prigent F, Gurewitz J, Friedman J, Berman D: Quantitative analysis of T1–201 myocardial single‐photon emission computerized rotational tomography: Development, validation and prospecting application of an optimized computerized method (abstr). J Am Coll Cardiol 1986; 7: 22A [Google Scholar]
- 51. De Pasquale EE, Nody AC, DePuey EG, Garcia EV, Pilcher G, Bredlau C, Roubin A, Gruentzig A, D'Amato P, Berger HJ: Quantitative rotational thallium‐201 tomography for identifying and localizing coronary artery disease. Circulation 1988; 77: 316–327 [DOI] [PubMed] [Google Scholar]
- 52. Egashira K, Inou T, Hirooka Y, Yamada A, Urabe Y, Takeshita A: Evidence of impaired endothelium‐dependent coronary vasodilation in patients with angina pectoris and normal coronary angiograms. N Engl J Med 1993; 328: 1659–1664 [DOI] [PubMed] [Google Scholar]
- 53. Quyyumi A, Cannon R, Panza J, Diodati J, Epstein S: Endothelial dysfunction in patients with chest pain and normal coronary arteries. Circulation 1992; 86: 1864–1871 [DOI] [PubMed] [Google Scholar]