A case of coronary microvascular spasm with slow flow induced by the intracoronary acetylcholine provocation test
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CASE REPORT
A case of coronary microvascular spasm with slow flow induced by the intracoronary acetylcholine provocation test Yasuhiro Tanabe • Kihei Yoneyama • Masaki Izumo • Ken Kongoji • Tomoo Harada Yoshihiro J. Akashi
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Received: 24 August 2014 / Accepted: 6 November 2014 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2014
Abstract Microvascular angina is a rare condition in which myocardial ischemia is caused by microvascular dysfunction without any abnormalities of the epicardial coronary arteries. In clinical practice, it is difficult to diagnose because the microvascular alterations cannot be detected by conventional angiography. Herein we present a rare case of a 67-year-old woman with unstable angina pectoris in whom considerably slow coronary flow was induced by the acetylcholine provocation test with mild epicardial arterial spasm, suggesting the presence of microvascular spasm. Moreover, we show that b-methyl-p-[123I]-iodophenyl-pentadecanoic (123I-BMIPP) single-photon emission computed tomography imaging is useful for proving myocardial ischemia.
microvascular dysfunction may also cause or contribute to myocardial ischemia and angina pectoris, which is known as microvascular angina or syndrome X [1]. In clinical practice, microvascular angina is a rare condition and is a diagnosis of exclusion because microvascular alterations cannot be detected by conventional angiography. Herein, we report a rare case of coronary microvascular spasm that was detected by a unique angiography finding during the acetylcholine provocation test. Myocardial ischemia was subsequently confirmed by b-methyl-p-[123I]-iodophenyl-pentadecanoic acid (123I-BMIPP) myocardial scintigraphy.
Keywords Microvascular angina Intracoronary acetylcholine provocation test 123I-BMIPP myocardial scintigraphy Slow flow
A 67-year-old woman with frequent chest pain was referred to our hospital in April 2014. She had hypertension and was treated with oral amlodipine 10 mg per day. Her symptoms included precordial pain at rest that did not occur with exertion and sublingual nitroglycerin was not so effective. Although her symptoms had improved on arrival and the blood examination revealed no increase in myocardial damage markers such as creatine phosphokinase (CPK) and troponin I, the electrocardiogram showed slight ST-T segment depression in leads I, II, III, aVL, aVF, and V4–6. She was diagnosed as unstable angina pectoris and admitted to the coronary care unit. She underwent cardiac catheterization the following day. On admission, an intravenous infusion of isosorbide dinitrate and nicorandil was started. However, the infusion was stopped 8 h before catheterization. Coronary angiography revealed no organic stenosis in the coronary arteries (Fig. 1). An acetylcholine provocation test was performed to detect any evidence of coronary artery spasm. First, graded acetylcholine doses of
Introduction Although myocardial ischemia is commonly caused by abnormalities of the epicardial coronary arteries, coronary
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