Overview
Transient contraction of the coronary arteries causes acute reduction or interruption of coronary blood flow caused by the syndrome is mainly manifested as chest tightness, chest pain and other symptoms, and even cause referred pain etiology and pathogenesis has not yet been clarified, smoking, alcohol, drugs, etc. can be triggered by the symptomatic person can be taken to the drug and surgical treatment.
Definition
Coronary artery spasm is a pathophysiologic state characterized by chest tightness and chest pain.
Coronary artery spasm is not a fixed stenosis of the coronary arteries, but rather a transient constriction of the coronary arteries that causes an acute interruption of coronary blood flow leading to myocardial ischemia [1-2].
Morbidity
Epidemiologic information on the overall population is lacking, and the available information is based on studies of high-risk individuals suspected of presenting with coronary artery spasm clinically due to chest pain.
The acetylcholine provocation test is the key test for confirming the diagnosis of coronary artery spasm, and the current statistics on coronary artery spasm are based on the results of the acetylcholine provocation test, which is described in detail in the diagnostic section of this term.
The results of a large multicenter investigative study in Japan showed a 43% positive rate of acetylcholine provocation test in patients with chest pain who had atherosclerosis on coronary angiography [3].
Another Korean study performed acetylcholine provocation test in patients with chest pain who showed no significant stenosis on coronary angiography and the positive rate was 48% [4].
In China, a small sample of people with resting chest pain and coronary angiographic stenosis <50% was reported to undergo an acetylcholine provocation test, with a positive rate of 75%, suggesting that our country may have a high prevalence of coronary artery spasm attacks [5].
Etiology
Causes
The etiology and pathogenesis of coronary artery spasm have not yet been clarified.
Risk factors
Smoking.
Lipid metabolism disorders.
Alcohol abuse.
Use of cocaine-containing drugs.
Lipid metabolism disorders.
Coronary atherosclerosis.
Coronary artery myocardial bridges [6].
Symptoms
Main symptoms
Typical coronary artery spasmodic angina (i.e., variant angina)
Angina attacks have a significant temporal regularity, most often occurring in the second half of the night through the morning hours, but can occur at other times as well.
The site of pain is often in the precordial area or behind the sternum.
The pain is crushing or constricting, accompanied by dyspnea and a sense of dying, lasting several minutes or more, and relieved by nitroglycerin.
There is a clear diurnal variation in the patient’s exercise tolerance, which can be triggered by light exertion in the early morning but not by strenuous physical activity in the late afternoon.
Atypical coronary artery spasm angina pectoris
Attacks occur easily at rest, especially in poorly ventilated environments.
The location of the pain is uncertain.
It is often characterized by mild chest tightness, most of which is of relatively long duration and is easily relieved by sympathetic stimulation such as fresh air and light physical activity [7].
Complications
Arrhythmia
Arrhythmia is an abnormality in the frequency, rhythm, site of origin, conduction velocity or order of excitation of the heart’s electrical impulses, which usually causes chest discomfort, palpitations, shortness of breath and other symptoms.
Myocardial infarction
It is characterized by crushing pain in the precordial region or behind the sternum, accompanied by dyspnea and a sense of near death.
Consultation
Department of Medicine
Cardiovascular Medicine
If symptoms such as chest tightness and chest pain occur, it is recommended to consult a doctor promptly.
Emergency Department
In the event of severe respiratory distress, fainting, shock, cardiac arrest, etc., it is recommended that you seek immediate medical attention or call the 120 emergency number for emergency services.
Preparation for medical treatment
Preparation for medical consultation: registration, preparation of documents, common problems
Tips for seeking medical treatment
The night before the consultation, pay attention to maintain emotional stability, do not stay up late to avoid causing sympathetic excitation, which may aggravate the condition.
Preparation List
Symptom list
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Are there symptoms of chest tightness or chest pain? How long have the symptoms been present?
Has there been any loss of consciousness?
Has there been a significant drop in blood pressure?
Is there any dyspnea?
Medical History List
Any previous history of angina pectoris?
Any history of drug allergy?
Checklist
Test results from the last 6 months to bring with you to your doctor’s appointment
Electrocardiogram, electrocardiogram exercise test, nuclear perfusion myocardial imaging, load test, non-traumatic provocation test, traumatic provocation test, etc.
List of medications
Medication use in the last 3 months, if available in boxes or packages, may be brought to the doctor’s office
Nitrates: nitroglycerin, isosorbide mononitrate
Calcium channel blockers: Diltiazem
Antiplatelet drugs: aspirin
Statins: Atorvastatin, Simvastatin
Beta-blockers: metoprolol succinate
Diagnosis
Diagnosis is based on
Medical history
History of hyperthyroidism, history of smoking and drinking, and risk factors such as drug use.
Clinical manifestations
Symptoms
Major symptoms such as chest tightness, chest pain, and even involving pain are present.
Electrocardiogram
The presence or absence of ST-segment ischemic changes can be recorded to determine the presence or absence of myocardial ischemia.
When coronary artery spasm is not present, the ECG usually shows no obvious abnormality.
ECG Exercise Test
Purpose of examination: To screen for underlying diseases such as coronary atherosclerosis.
Significance of the examination: It can make the diagnosis more clearly.
Precautions: The patient’s mental state should be kept stable and the nutrition should be balanced.
Nuclide Perfusion Myocardial Imaging Load Test
Purpose of examination: to clarify whether there is myocardial injury and myocardial blood supply.
Significance: It can observe the severity of coronary artery spasm.
Precautions: The patient’s heart rate, blood pressure and ECG should be monitored throughout.
Coronary Angiography
Coronary arteries are injected with a contrast medium to visualize them under X-ray, which can be used to differentiate between coronary artery stenosis and spasm.
At the end of the imaging procedure, an atraumatic drug provocation test may be performed to further diagnose coronary artery spasm in patients who do not have stenosis.
Non-traumatic provocation tests
Hyperventilation combined with cold pressor test
Purpose of the test: To confirm the presence of coronary artery spasm syndrome.
Significance of the test: If, at the time of the test, there are typical symptoms of chest pain, an ST-segment shift of ≥0.1mV on the electrocardiogram, or an echocardiogram showing emerging ventricular wall motion abnormalities, this may help in the diagnosis.
Precautions to be taken during the examination: it should only be performed in hospitals with the necessary conditions.
Combined hyperventilation and exercise test
Purpose of the test: To confirm the presence of coronary artery spasm syndrome
Significance of the test: May be helpful in diagnosis if typical chest pain syndrome is present during the test examination.
Traumatic excitation test
Differential diagnosis is possible in determining whether vasospastic angina is present.
It mainly includes ergometrine provocation test and acetylcholine provocation test, and the diagnosis is made by whether the two drugs can induce coronary artery spasm.
It is mainly used in patients with chest pain or chest tightness who do not have significant fixed stenosis on coronary angiography.
Differential Diagnosis
Some coronary artery spasms with atypical history and clinical manifestations are often confused with the following diseases and should be differentiated.
Acute pericarditis
Similarities: ST-segment changes and pain in the precordial region are present on the ECG.
Differences: Pericarditis may be preceded by fever and elevated white blood cell counts, and the pain is often exacerbated by deep breathing and coughing.
Acute pulmonary embolism
Similarities: Both are associated with chest pain.
Differences: The electrocardiogram in pulmonary embolism shows a rightward deviation of the electrical axis and inversion of the Q and T waves.
Aortic dissection
Similarities: both present with severe chest pain.
Differences: aortic dissection often radiates to the back, ribs, abdomen, waist, and lower extremities, and aortic coarctation can also be diagnosed by X-ray, CT, and MRI [8].
Treatment
The purpose of treatment: to relieve coronary artery spasm, timely management of complications, and avoid recurrent episodes.
Treatment principle: drug treatment is the mainstay, and surgery can be considered when combined with other conditions.
Acute stage
Drug treatment
Nitroglycerin
It can prevent vasoconstriction, promote vasodilation and relieve symptoms.
It can be taken under the tongue for faster effect. Besides, it should be prohibited for those who are allergic to this drug, and also prohibited for those with low blood pressure.
Calcium channel blockers
Commonly used drugs such as diltiazem.
They can promote coronary vasodilation.
It is contraindicated for those who are allergic to these drugs; long-term use may cause nausea and vomiting, and should be monitored regularly.
Antiplatelet therapy
Commonly used drugs such as aspirin and Tegretol.
Persistent spasms often progress to acute myocardial infarction or sudden death and require early initiation of antiplatelet therapy.
Bleeding, skin petechiae and ecchymosis may occur.
Stabilization period
Control risk factors and predisposing factors
Stop smoking and alcohol.
Control blood pressure.
Maintain appropriate body weight, not overweight nor excessively thin.
Correct blood sugar and lipid metabolism disorders.
Avoid overwork and mental stress.
Medication
Calcium channel blockers
Commonly used drugs are diltiazem, nifedipine, amlodipine, benidipine and so on.
They can promote coronary vasodilation.
Allergic to these drugs is prohibited; long-term use may cause nausea and vomiting and other symptoms.
Nitrates
Commonly used drugs are nitroglycerin, isosorbide mononitrate and so on.
They can prevent vasoconstriction, promote vasodilation and relieve symptoms.
Oral administration can also be effective, sublingual effect is faster, in addition to allergy to this drug should be prohibited, while patients with low blood pressure is also prohibited.
Potassium channel opener
Nicorandil is commonly used.
It can increase coronary blood flow without affecting blood pressure, heart rate and cardiac conduction system, and will not be resistant to the drug. It can relieve tension, reduce myocardial oxygen consumption and relieve angina pectoris.
Contraindicated in cardiogenic shock, with left ventricular failure, and hypotension.
Antiplatelet therapy
Commonly used drugs include aspirin and clopidogrel.
May prevent acute coronary events.
Bleeding, skin petechiae ecchymosis and other manifestations may occur.
Statins
Commonly used drugs include atorvastatin, simvastatin.
Effective in preventing coronary artery spasm and may improve endothelial function.
Non-pharmacologic treatment
Percutaneous coronary intervention
In principle, patients with simple coronary artery spasm do not need intervention.
However, some patients may be combined with moderate to severe coronary artery stenosis, which can be treated with percutaneous coronary intervention.
Buried automatic defibrillation pacemaker
For patients with sustained tachycardia or ventricular fibrillation induced by coronary artery spasm leading to cardiac arrest, the installation of a buried automatic defibrillation pacemaker can be considered after drug treatment is ineffective [9].
Prognosis
Cured
Untreated
Untreated disease progression may occur, resulting in acute myocardial infarction, malignant arrhythmias, and in severe cases, cardiac arrest, leading to life-threatening conditions.
After treatment
Coronary artery spasm is generally well treated after medication as well as surgery, and recurrence is reduced, which can improve the quality of life.
Patients who adhere to long-term medication based on strict abstinence from smoking and alcohol generally have a good prognosis, with long-term follow-up mortality rates of about 1% in both Japan and China.
Harmful
Daily life
Long-term symptoms such as chest tightness and chest pain may interfere with life.
Mental health
The disease has a long course but is prone to recurrence, and patients are prone to worry and other negative emotions.
Lethality
It may cause myocardial infarction, etc., and is prone to life-threatening conditions and even death.
Daily
Daily management
Dietary management
Maintain a light diet low in salt and fat and eat more fresh vegetables.
Avoid high salt and high fat food such as pickled food and fried food.
Abstain from alcohol.
Life Management
Avoid staying up late, go to bed early and get up early to maintain a good lifestyle.
Quit smoking and avoid second-hand smoke.
Exercise management
Maintain regular and moderate physical activity.
Psychological Support
Receive health education to learn about coronary artery spasm and correct any misconceptions about the disease.
You can also seek help from medical staff and psychological counseling if necessary, so as not to affect the therapeutic effect due to psychological problems.
Disease monitoring
Patients should self-record the chest pain episodes and their duration after treatment, and should consult the doctor promptly when symptoms such as chest pain and chest tightness occur.
Prevention
As the cause of coronary artery spasm is not yet clear, it is difficult to prevent, and high-risk factors should be avoided.
Regular physical examination
Regular medical checkups should be conducted every year to detect diseases and treat them promptly.
Lifestyle changes
Maintain a regular routine and avoid staying up late.
Maintain regular and moderate physical exercise, such as jogging, etc., at an intensity that does not make you feel tired after exercise.
Maintain a positive mindset.
Stop smoking and drinking [10].