Skip to main content
Top
Published in: Clinical Research in Cardiology 2/2020

01-02-2020 | Nitrate | Original Paper

Microvascular spasm in non-ST-segment elevation myocardial infarction without culprit lesion (MINOCA)

Authors: Giancarlo Pirozzolo, Andreas Seitz, Anastasios Athanasiadis, Raffi Bekeredjian, Udo Sechtem, Peter Ong

Published in: Clinical Research in Cardiology | Issue 2/2020

Login to get access

Abstract

Background

Up to 30% of patients with acute coronary syndrome have no culprit lesion. Coronary microvascular spasm is an alternative cause for such a clinical presentation. However, this has rarely been investigated systematically. The aim of our study was to assess the frequency of coronary microvascular spasm in patients with NSTEMI without culprit lesion (MINOCA) by intracoronary acetylcholine testing (ACH-test).

Methods

Between 2014 and 2017, 940 patients with NSTEMI underwent coronary angiography and 125 (13%) had no culprit lesion (< 50% stenosis on visual assessment). Of the latter, 29 patients had other causes for the clinical presentation (e.g. tako-tsubo-syndrome or myocarditis). The remaining 96 patients were recruited for the study and underwent ACH-testing according to a standardized protocol.

Results

The ACH-test was normal in 40 (42%) and abnormal in the remaining 56 (58%) patients. Of the latter, 26 patients (46%) had epicardial spasm (epicardial narrowing ≥ 90%, reproduction of symptoms and ischemic ST-segment changes) and 30 (54%) microvascular spasm (ischemic ST-shifts and angina without epicardial vasoconstriction ≥ 90%). The peak high-sensitive troponin-T concentration was 113 (42–255) pg/ml. Patients with coronary spasm had more often a positive family history compared to those without and patients with epicardial compared to microvascular spasm were more often smokers.

Conclusion

Coronary microvascular spasm is frequently found in patients with NSTEMI without culprit lesion and represents a likely cause of myocardial injury. ACH-testing is useful for detection of vasomotor disorders allowing tailored treatment with calcium antagonists and/or nitrates in addition to secondary prevention to improve symptoms and prognosis.

Graphic abstract

Microvascular spasm in non-ST-segment elevation myocardial infarction without culprit lesion (MINOCA) .
Appendix
Available only for authorised users
Literature
1.
go back to reference Hochman JS, Tamis JE, Thompson TD et al (1999) Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIb investigators. N Engl J Med 341:226–232CrossRef Hochman JS, Tamis JE, Thompson TD et al (1999) Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIb investigators. N Engl J Med 341:226–232CrossRef
2.
go back to reference Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD (2019) ESC scientific document group. Fourth universal definition of myocardial infarction (2018). Eur Heart J 40:237–269CrossRef Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD (2019) ESC scientific document group. Fourth universal definition of myocardial infarction (2018). Eur Heart J 40:237–269CrossRef
3.
go back to reference Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, De Caterina R, Zimarino M, Roffi M, Kjeldsen K, Atar D, Kaski JC, Sechtem U, Tornvall P (2017) WG on cardiovascular pharmacotherapy. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J 38:143–153PubMed Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, De Caterina R, Zimarino M, Roffi M, Kjeldsen K, Atar D, Kaski JC, Sechtem U, Tornvall P (2017) WG on cardiovascular pharmacotherapy. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J 38:143–153PubMed
5.
go back to reference Sandoval Y, Thordsen SE, Smith SW, Schulz KM, Murakami MM, Pearce LA, Apple FS (2014) Cardiac troponin changes to distinguish type 1 and type 2 myocardial infarction and 180-day mortality risk. Eur Heart J Acute Cardiovasc Care 3:317–325CrossRef Sandoval Y, Thordsen SE, Smith SW, Schulz KM, Murakami MM, Pearce LA, Apple FS (2014) Cardiac troponin changes to distinguish type 1 and type 2 myocardial infarction and 180-day mortality risk. Eur Heart J Acute Cardiovasc Care 3:317–325CrossRef
6.
go back to reference Ong P, Athanasiadis A, Hill S, Vogelsberg H, Voehringer M, Sechtem U (2008) Coronary artery spasm as a frequent cause of acute coronary syndrome: the CASPAR (coronary artery spasm in patients with acute coronary syndrome) study. J Am Coll Cardiol 52:523–527CrossRef Ong P, Athanasiadis A, Hill S, Vogelsberg H, Voehringer M, Sechtem U (2008) Coronary artery spasm as a frequent cause of acute coronary syndrome: the CASPAR (coronary artery spasm in patients with acute coronary syndrome) study. J Am Coll Cardiol 52:523–527CrossRef
7.
go back to reference Wang CH, Kuo LT, Hung MJ et al (2002) Coronary vasospasm as a possible cause of elevated cardiac troponin I in patients with acute coronary syndrome and insignificant coronary artery disease. Am Heart J 144:275–281CrossRef Wang CH, Kuo LT, Hung MJ et al (2002) Coronary vasospasm as a possible cause of elevated cardiac troponin I in patients with acute coronary syndrome and insignificant coronary artery disease. Am Heart J 144:275–281CrossRef
8.
go back to reference Nakayama N, Kaikita K, Fukunaga T, Matsuzawa Y, Sato K, Horio E, Yoshimura H, Mizobe M, Takashio S, Tsujita K, Kojima S, Tayama S, Hokimoto S, Sakamoto T, Nakao K, Sugiyama S, Kimura K, Ogawa H (2014) Clinical features and prognosis of patients with coronary spasm-induced non-ST-segment elevation acute coronary syndrome. J Am Heart Assoc 3:e000795CrossRef Nakayama N, Kaikita K, Fukunaga T, Matsuzawa Y, Sato K, Horio E, Yoshimura H, Mizobe M, Takashio S, Tsujita K, Kojima S, Tayama S, Hokimoto S, Sakamoto T, Nakao K, Sugiyama S, Kimura K, Ogawa H (2014) Clinical features and prognosis of patients with coronary spasm-induced non-ST-segment elevation acute coronary syndrome. J Am Heart Assoc 3:e000795CrossRef
9.
go back to reference Yu M, Zhang Q, Huang X (2018) Acute coronary syndrome due to right coronary spasm and documented lambda-like J waves. Clin Res Cardiol 107:729–732CrossRef Yu M, Zhang Q, Huang X (2018) Acute coronary syndrome due to right coronary spasm and documented lambda-like J waves. Clin Res Cardiol 107:729–732CrossRef
10.
go back to reference Montone RA, Niccoli G, Fracassi F, Russo M, Gurgoglione F, Cammà G, Lanza GA, Crea F (2018) Patients with acute myocardial infarction and non-obstructive coronary arteries: safety and prognostic relevance of invasive coronary provocative tests. Eur Heart J 39:91–98PubMed Montone RA, Niccoli G, Fracassi F, Russo M, Gurgoglione F, Cammà G, Lanza GA, Crea F (2018) Patients with acute myocardial infarction and non-obstructive coronary arteries: safety and prognostic relevance of invasive coronary provocative tests. Eur Heart J 39:91–98PubMed
11.
go back to reference Grodzinsky A, Arnold SV, Gosch K, Spertus JA, Foody JM, Beltrame J, Maddox TM, Parashar S, Kosiborod M (2015) Angina frequency after acute myocardial infarction in patients without obstructive coronary artery disease. Eur Heart J Qual Care Clin Outcomes 1:92–99CrossRef Grodzinsky A, Arnold SV, Gosch K, Spertus JA, Foody JM, Beltrame J, Maddox TM, Parashar S, Kosiborod M (2015) Angina frequency after acute myocardial infarction in patients without obstructive coronary artery disease. Eur Heart J Qual Care Clin Outcomes 1:92–99CrossRef
12.
go back to reference Task Force Members, Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Taggart DP, van der Wall EE, Vrints CJ, ESC Committee for Practice Guidelines, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Document Reviewers, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, Gonzalez-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Kristensen SD, Lancellotti P, Maggioni AP, Piepoli MF, Pries AR, Romeo F, Rydén L, Simoons ML, Sirnes PA, Steg PG, Timmis A, Wijns W, Windecker S, Yildirir A, Zamorano JL (2013) ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European society of cardiology. Eur Heart J 2013(34):2949–3003 Task Force Members, Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Taggart DP, van der Wall EE, Vrints CJ, ESC Committee for Practice Guidelines, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Document Reviewers, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, Gonzalez-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Kristensen SD, Lancellotti P, Maggioni AP, Piepoli MF, Pries AR, Romeo F, Rydén L, Simoons ML, Sirnes PA, Steg PG, Timmis A, Wijns W, Windecker S, Yildirir A, Zamorano JL (2013) ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European society of cardiology. Eur Heart J 2013(34):2949–3003
13.
go back to reference Yilmaz A, Mahrholdt H, Athanasiadis A, Vogelsberg H, Meinhardt G, Voehringer M, Kispert EM, Deluigi C, Baccouche H, Spodarev E, Klingel K, Kandolf R, Sechtem U (2008) Coronary vasospasm as the underlying cause for chest pain in patients with PVB19 myocarditis. Heart 94:1456–1463CrossRef Yilmaz A, Mahrholdt H, Athanasiadis A, Vogelsberg H, Meinhardt G, Voehringer M, Kispert EM, Deluigi C, Baccouche H, Spodarev E, Klingel K, Kandolf R, Sechtem U (2008) Coronary vasospasm as the underlying cause for chest pain in patients with PVB19 myocarditis. Heart 94:1456–1463CrossRef
14.
go back to reference Sueda S, Kohno H, Ochi T, Uraoka T, Tsunemitsu K (2017) Overview of the pharmacological spasm provocation test: comparisons between acetylcholine and ergonovine. J Cardiol 69:57–65CrossRef Sueda S, Kohno H, Ochi T, Uraoka T, Tsunemitsu K (2017) Overview of the pharmacological spasm provocation test: comparisons between acetylcholine and ergonovine. J Cardiol 69:57–65CrossRef
15.
go back to reference Gross L, Epstein EZ, Kugel MA (1934) Histology of the coronary arteries and their branches in the human heart. Am J Pathol 10(253–274):7PubMed Gross L, Epstein EZ, Kugel MA (1934) Histology of the coronary arteries and their branches in the human heart. Am J Pathol 10(253–274):7PubMed
16.
go back to reference Thorin E (2001) Influence of nitric oxide synthase inhibition and endothelin-1 receptor blockade on acetylcholine-induced coronary artery contraction in vitro in dilated and ischemic cardiomyopathies. J Cardiovasc Pharmacol 38:90–98CrossRef Thorin E (2001) Influence of nitric oxide synthase inhibition and endothelin-1 receptor blockade on acetylcholine-induced coronary artery contraction in vitro in dilated and ischemic cardiomyopathies. J Cardiovasc Pharmacol 38:90–98CrossRef
17.
go back to reference Pelliccia F, Kaski JC, Crea F, Camici PG (2017) Pathophysiology of takotsubo syndrome. Circulation 135:2426–2441CrossRef Pelliccia F, Kaski JC, Crea F, Camici PG (2017) Pathophysiology of takotsubo syndrome. Circulation 135:2426–2441CrossRef
18.
go back to reference Gassanov N, Le MT, Caglayan E, Hellmich M, Erdmann E, Er F (2019) Novel ECG-based scoring tool for prediction of takotsubo syndrome. Clin Res Cardiol 108:68–73CrossRef Gassanov N, Le MT, Caglayan E, Hellmich M, Erdmann E, Er F (2019) Novel ECG-based scoring tool for prediction of takotsubo syndrome. Clin Res Cardiol 108:68–73CrossRef
Metadata
Title
Microvascular spasm in non-ST-segment elevation myocardial infarction without culprit lesion (MINOCA)
Authors
Giancarlo Pirozzolo
Andreas Seitz
Anastasios Athanasiadis
Raffi Bekeredjian
Udo Sechtem
Peter Ong
Publication date
01-02-2020
Publisher
Springer Berlin Heidelberg
Published in
Clinical Research in Cardiology / Issue 2/2020
Print ISSN: 1861-0684
Electronic ISSN: 1861-0692
DOI
https://doi.org/10.1007/s00392-019-01507-w

Other articles of this Issue 2/2020

Clinical Research in Cardiology 2/2020 Go to the issue