Clin Res Cardiol (2021). 10.1007/s00392-021-01933-9

Structural or functional coronary artery disease? Acetylcholine testing reveals epicardial spasm after multiple myocardial revascularizations
S. Fröbel1, J. McChord1, V. Martinez Pereyra1, R. Bekeredjian1, P. Ong1
1Innere Medizin III / Kardiologie, Robert-Bosch-Krankenhaus, Stuttgart;

Determining the cause of angina pectoris remains challenging, because structural and functional abnormalities may be involved. We report the case of a 77-year-old male patient who presented with recurrent chest pain. His past medical history was notable for single coronary bypass of a proximal left anterior descending artery (LAD) stenosis in 1989 using the left internal thoracic artery (LITA). After degeneration of the LITA-bypass, coronary bypass surgery was repeated with a venous graft to the LAD in 1995. The patient reported ongoing symptoms with chest pain now predominantly occurring at rest and during night time. He also reported radiation into the throat area. In addition, during or after each chest pain attack, a persistent trembling in the extremities and a strong feeling of cold was observed. He continued to be severely impaired in his daily activities. Several coronary angiographies were performed in search of progression of coronary artery disease showing a patent venous LAD-bypass. In 2016 another angiogram revealed occlusion of the LAD-bypass. Subsequently, percutaneous intervention (PCI) of the LAD was performed with 3 stents. However, the patient’s symptoms did not improve although antianginal drugs such as amlodipine and carvedilol were initiated. In 2020 a myocardial scintigraphy examination did not reveal any reversible ischemia. Finally, we decided to perform an invasive diagnostic procedure suspecting a coronary vasomotor disorder as the cause of the symptoms in 2021. Intracoronary acetylcholine testing revealed diffuse epicardial spasms of the LAD distal to the stents as well as of the left circumflex artery. The acetylcholine test revealed a CFRACH of 1.6. The spasms were accompanied with reproduction of the patient’s symptoms and ischemic ECG changes. Coronary flow reserve and hyperaemic microvascular resistance in response to intracoronary adenosine were within normal limits (2.7 and 1.4 mmHg/cm/sec, respectively).Ranolazine and carvedilol were discontinued and treatment with a second calcium antagonist (i. e. diltiazem) in addition to amlodipine was initiated. At follow-up the patient’s angina had significantly improved. Coronary spasm in patients with previous bypass operation but no relevant stenosis is not an infrequent finding. In a recent study by Pirozzolo et al. it was shown that 81% of such patients had epicardial or microvascular spasm during acetylcholine testing via the LITA graft. In contrast, spasm of the bypass graft could not be documented. However, this has been described in the intra- or perioperative phase. In conclusion, chest pain at rest with no significant or obstructive disease as the predominant symptom should prompt testing for coronary spasm in order to initiate appropriate anti-vasospastic medication.


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