Role of acetylcholine spasm provocation test as a pathophysiological assessment in nonobstructive coronary artery diseas
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INVITED REVIEW ARTICLE
Role of acetylcholine spasm provocation test as a pathophysiological assessment in nonobstructive coronary artery disease Satoru Suzuki1 · Koichi Kaikita1 · Eiichiro Yamamoto1 · Hideaki Jinnouchi2 · Kenichi Tsujita1 Received: 7 October 2020 / Accepted: 8 October 2020 © The Author(s) 2020
Abstract Coronary angiography (CAG) sometimes shows nonobstructive coronary arteries in patients with suspected angina or acute coronary syndrome (ACS). The high prevalence of nonobstructive coronary artery disease (CAD) in those patients has recently been reported not only in Japan but also in Western countries, and is clinically attracting attention. Coronary spasm is considered to be one of the leading causes of both suspected stable angina and ACS with nonobstructive coronary arteries. Coronary spasm could also be associated with left ventricular dysfunction leading to heart failure, which could be improved following the administration of calcium channel blockers. Because we rarely capture spontaneous attacks of coronary spasm with electrocardiograms or Holter recordings, an invasive diagnostic modality, acetylcholine (ACh) provocation test, can be useful in detecting coronary spasm during CAG. Furthermore, we can use the ACh-provocation test to identify high-risk patients with coronary spasm complicated with organic coronary stenosis, and then treat with intensive care. Nonobstructive CAD includes not only epicardial coronary spasm but also microvascular spasm or dysfunction that can be associated with recurrent anginal attacks and poor quality of life. ACh-provocation test could also be helpful for the assessment of microvascular spasm or dysfunction. We hope that cardiologists will increasingly perform ACh-provocation test to assess the pathophysiology of nonobstructive CAD. Keywords Coronary spasm · Acetylcholine provocation test · Nonobstructive coronary artery disease · Microvascular spasm
Introduction We often perform percutaneous coronary intervention (PCI) with coronary stent implantation for significant organic coronary artery stenosis with induced myocardial ischemia. PCI has become a useful treatment for relief of chest symptom in patients with significant coronary organic stenosis. However, coronary angiography (CAG) sometimes shows nonobstructive coronary arteries that do not need revascularization in patients with suspected angina [1–11]. Indeed, more than 50% of stable patients with suspected angina undergoing * Koichi Kaikita kaikitak@kumamoto‑u.ac.jp 1
Department of Cardiovascular Medicine and Center for Metabolic Regulation of Healthy Aging, Graduate School of Medical Sciences, Kumamoto University, 1‑1‑1 Honjo, Chuo‑ku, Kumamoto 860‑8556, Japan
Diabetes Center, Jinnouchi Hospital, 6‑2‑3 Kuhonji, Chuo‑ku, Kumamoto 862‑0976, Japan
2
CAG had angiographically nonobstructive coronary arteries that did not require revascularization [4, 10]. In addition, despite the high prevalence of obstructive coronary artery disease (CAD) in acute myocardial infarction (AMI), up to 13% of AMI
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