Diagnostic Challenges

Transcription

1 Mechanisms and Outcome of Vasospastic Angina Diagnostic Challenges Udo Sechtem Robert-Bosch-Krankenhaus Stuttgart, Germany

2 I have nothing to disclose.

3 Coronary spasm does it exist at all? And if it does, what does it look like?

4 Acetylcholine Testing Baseline Angiography Control CA CA CA CA 1 min. 3 min. 3 min. 3 min. 3 min. 1 min. Acetylcholine 2µg (10-7 mol/l) slowly i. c. over 3 min. ACH 100µg ACH 200µg Acetylcholine 20µg Nitroglycerin i.c. Herz 2005;30:17-25

5 A Typical History 62 y old lady with repetitive attacks of resting angina. Some dyspnoea upon exertion. CVRF: smoker, arterial hypertension with large changes in blood pressure, family history: father MI at age 65. Exercise-ECG at 100W stopped due to exertion: mild angina, no ST-segment changes Cardiologist recommends ICA

6 M.M. - ACH-Test LCA LCA NTG LCA ACH 100µg

7 LCA baseline LCA ACH 100µg

8 54 y Old Lady With Resting Angina, Nausea and Syncope

9 No Wonder!

10 Spontaneous Spasm (Prinzmetal Type) RCA RCA p NTG

11 Case Presentation 81y old woman Strictly exercise related chest pain for years CVRF: arterial hypertension, hypercholesterolemia ER presentation: thoracic pain at low level exercise, associated with anxiety and nausea, several instances of collapse at home, comes because of collapse an hour earlier

12 ACh 100µg Microvascular Spasm NTG

13 When To Think of Vasospasm? Unstable angina (resting angina) with normal coronaries or coronaries with plaque with coronary stenoses but normal flow and remaining lumen 1mm with high grade coronary stenosis (NTG before PCI!!)

14 Normal Coronary Arteries With ACS Hochman J et al. N Engl J Med 341:226-32, 1999 (GUSTO-Studie)

15 ACS Without Coronary Artery Stenosis Ong P et al. J Am Coll Cardiol 2008;52:523-7

16 Summary (1) Resting angina (ACS) often without high grade stenoses at angiography Common cause: diffuse, distally pronounced spasm of the CA Often diffuse underlying CAD (diabetics, hypertensive pts, smokers!) Important question in the cath lab: can this stenosis really cause resting angina?? Before PCI: pressure wire! acetylcholine!

17 When To Think of Functional Coronary Disease? (usually due to MVD = reduced coronary reserve) Exercise-related symptoms (mainly dyspnoea on exertion) without unequivocal culprit lesion Combination of exercise related dyspnoea/angina and resting angina without unequivocal culprit lesion

18 Healthy Patients With Stable Angina?

19 Only 1/4 Women Undergoing CA Has Significant Stenoses! Patel MR et al. N Engl J Med 2010;362: (%) p<0, p<0, Men Women 0 70% stenosis No significant stenosis

20 Functional CAD in Pts With Stable Angina But No Significant Stenoses Ong P et al. J Am Coll Cardiol 2012;59:

21 A Lady With Exercise-Related Dyspnoe/Angina Plus Angina at Rest Since 1997 Coronary angiography 2010

22 Vein Grafts to RM and RD Coronary angiography 2010

23 Coronary angiography 2010 IMA LAD

24 Acetylcholine LCA Coronary angiography 2010 Baseline ACH 200 µg

25 EKG During Acetylcholine Testing Baseline ACH 200 µg

26 Acetylcholine Testing ACH 200 µg NTG

27 2001

28 ACH-Testing in Patients With Recurrent AP Following Stenting Ong P et al. J Am Coll Cardiol (under review)

29 Reproduction of Symptoms During Acetylcholine Ong P et al. J Am Coll Cardiol (under review) ACH 100 µg NTG

30 Summary (2) Very frequent problem in the community: stable and unstable angina c/o stenosing CAD Cause of resting angina often coronary spasm cause of exercise related symptoms often MVD both may occur together Difficult identification of functional disease in cath lab in pts with symptoms and angiographic CAD including stenosi(e)s of unknown significance Hypothesis: often stent placement in nonsignificant stenosis

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32 Spasm Testing With Recurrent AP post Stenting Ong P et al. J Am Coll Cardiol (under review) Acetylcholin testing Epic. spasm 49% Microvasc. Spasm 18% Normal 33%

33 Does It Matter Knowing the Diagnosis? Einzelfall?? Data from WISE?? Rutledge depression

34 Case Aortic Stenosis Frau Braun wird Webpax gehen?

35 Programme Different forms of vasospastic angina Epicardial Microvascular Associations of vasospastic (resting) angina with Microvascular angina Epicardial coronary disease Aortic stenosis