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Abstract
Background
Noninvasive diagnostic test to document coronary artery spasm would be useful in the management of patients with variant angina, especially in the screening, evaluation of the medication effects and determination of the clinical activity of the disease. The purpose of this study was to evaluate the clinical feasibility of bedside ergonovine test with digital echocardiography and side-by-side continuous cine-loop display method (ergonovine echocardiography) as a noninvasive diagnostic method for coronary artery spasm.
Methods
Bedside ergonovine test was performed in 66 patients who showed coronary vasospasm during coronary angiography including provocation test (variant angina group) and in 39 patients with normal angiogram and no evidence of coronary artery spasm(nonanginal pain group). A bolus of ergonovine maleate (.025 or .05mg) was injected at 5 min intervals up to total cumulative dosage of .35mg, and 12-leads ECG and 2 dimensional echocardiography were recorded every 3min after each injection. Left ventricular wall motion was analyzed with a commercially available ‘QUAD’ system. The positive criteria of bedside ergonovine test included reversible ST segment elevation or depression in ECG (ECG criteria) and reversible regional wall motion abnormalities in echocardiography (Echo criteria).
Results
The overall sensitivity and specificity of ECG criteria were 53% (35/66, 95% confidence interval[CI], 41 to 65%) and 100% respectively. By Echo criteria the sensitivity increased up to 89% (59/66, 95% CI, 81 to 97%) with the specificity of 95% (37/39). Concomitant fixed coronary lesion increased the sensitivity of the test compared with pure coronary artery spasm with ECG criteria (95% vs 35%, p<0.05). According to Echo criteria mean dose of ergonovine with positive result was 150 ± 75μg and the amount of ergonovine for positive result was significantly larger in patients with low disease activity (chest pain <5 times a week) than those with high disease activity(207 ± 81 vs 106 ± 73μg p<0.01): concomitant mild fixed coronary disease decreased the ergonovine dosage compared with pure coronary vasospasm (93 ± 65 vs 168 ± 102μg, p<0.05). There was no procedure related serious arrhythmias nor fatality.
Conclusion
Ergonovine echocardiography is a highly sensitive and specific test for coronary vasospasm and is safe in selected patients in whom the noninvasive stress test is negative and severe fixed coronary artery disease has been excluded. Presence of concomitant fixed coronary disease and the degree of clinical activity of coronary vasospasm may influence the results of this test.
References
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Fig. 1.
An example of ergonovine echocardiography in a patient with documented coronary vasospasm in the right coronary artery. Left ventricular(LV) wall motion at end systole was displayed in ‘QUAD’ screen. No definite regional wall motion abnormality at basal status(A) and after 0.05mg ergonovine injection(B). With 0.1 mg ergonovine injection severe hypokinesia and akinesia with loss of systolic wall thickening developed in mid inferior segment, which resulted in so-called ‘cavitary sign’(C). These wall motion abnormalities reversed promptly with nitroglycerin admmistration(D).
Table 1.
Demographic data
| Variant Angina | Nonanginal Pain | |
|---|---|---|
| Total Number | 66 | 39 |
| Male/Female | 55/11 | 18/21 |
| Age(mean±SD) | 54 ± 8 | 55 ± 10 |
| Clinical Data | spontaneous spasm | normal coronary artery |
| (+) provocation test∗ | (–) provocation test∗ |
Table 2.
Clinical charateristics of patients with variant angina
| Variant Angina (N = 66) | |
|---|---|
| Male/Famale | 55/11 |
| High activity∗/Low activity | 29/37 |
| Pure spasm/Mixed disease∗∗ | 46/20 |
| Single vessel spasm/Multi vessel spasm | 52/14 |
| Spasm-documented vessel LAD/RCA/LCX | 37/33/12 |
Table 3.
Results of bedside ergonovine test
| Variant Angina (N = 66) | Nonanginal Pain (N = 39) | |
|---|---|---|
| Chest pain or discomfort | 57/66(85%) | 16/39(41%) |
| Reversible ECG changes∗ | 35/66(53%) | 0/39(0%) |
| Reversible RWMA in Echo | 59/66(89%) | 2/39(5%) |
Table 4.
Sensitivity and specificity of bedside ergonovine test
Table 5.
Factors affecting the sensitivity of the test
| ECG criteria | Echo criteria | |
|---|---|---|
| Low activity | 15/37(41%) | 30/37(81%) |
| High activity | 20/29(69%) | 29/29(100%) |
| Pure spasm | 16/46(35%)∗ | 39/46(85%) |
| Mixed disease | 19/20(95%) | 20/20(100%) |
| Single vessel spasm | 25/52(48%) | 45/52(87%) |
| Multi vessel spasm | 10/14(71%) | 14/14(100%) |
Table 6.
Sensitivity of ergonovine echocardiography according to the methods of spasm documentation during coronary angiography
| Methods of Spasm Documentation During Angiography | Ergonovine Echocardiography (Echo Criteria) | ||
|---|---|---|---|
| Positive | Negative | Sensitivity | |
| Spontaneous | |||
| Spasm(N = 22) | 21 | 1 | 95% |
| IC Ach∗ | |||
| (+) Spasm(N = 23) | 18 | 5 | 78% |
| (–) Spasm(N=19) | 2 | 17 | |
| IV Erg∗∗ | |||
| (+) Spasm(N = 21) | |||
| (–) Spasm(N = 20) | 0 | 20 | |
Table 7.
Ergonovine dose (mean± S.D., g) of positive bedside ergonovine test with Echo criteria(N = 59) according to the subgroups of patients with variant angina
| Ergonovine Dose | p-value | |
|---|---|---|
| Low Activity | 207 ± 81 | p<0.05 |
| High Activity | 106 ± 73 | |
| Pure Spasm | 168 ± 102 | p<0.05 |
| Mixed Disease | 93 ± 65 | |
| Single vessel spasm | 173 ± 92 | p>0.1 |
| Multi vessel spasm | 153 ± 95 |
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