Relation between severity of myocardial bridge and vasospasm

doi:10.1016/j.ijcard.2017.07.002

International Journal of Cardiology

Volume 248, 1 December 2017, Pages 34-38

https://doi.org/10.1016/j.ijcard.2017.07.002 Get rights and content

Abstract

Background

Myocardial bridge (MB) has been reported to induce cardiac complications including coronary vasospasm. Although MB has some anatomical and morphological variations, the association of these variations with vasospasm is unclear. The aim of this study was to investigate the relation between morphological severity of MB and vasospasm induced by acetylcholine (ACh) provocation test.

Methods

A total of 392 patients without coronary stent in the left anterior descending artery (LAD) undergoing intracoronary ACh provocation test were included. Angiographic coronary artery vasospasm was defined as total or subtotal occlusion induced by ACh provocation. MB was identified on coronary angiography as a milking effect. Total bridged length and maximum percent systolic compression of MB in the LAD were analyzed quantitatively.

Results

MBs in the LAD were identified in 140 patients (36%), mostly in the mid segment. Patients with MB in the LAD had greater number of provoked vasospasm in the LAD and positive ACh provocation test compared to those without. The bridged length positively correlated with percent systolic compression of MB (r = 0.37, p < 0.001). In the receiver operating characteristic curve analysis, both bridged length and percent systolic compression of MB significantly predicted the provoked LAD spasm (AUC 0.74, p < 0.001, and AUC 0.68, p < 0.001). Multivariate regression analysis demonstrated these factors as independent predictors for provoked LAD spasm.

Conclusion

MB, especially morphologically severe MB, may induce greater coronary vasospasm.

Introduction

Myocardial bridge (MB), partially overlying the coronary artery, is a congenital anatomical variant, and it mostly involves the left anterior descending coronary artery (LAD) [1], [2], [3]. Although MB has been traditionally considered a benign anatomy [4], the association of MB with cardiac complications has been reported in many cases, such as coronary atherosclerosis [5], myocardial ischemia [6], [7], acute coronary syndrome [8], and sudden cardiac death [9]. On the other hand, vasospastic angina is also an important cardiac disorder that causes adverse events [10], [11], and intracoronary acetylcholine (ACh) provocation test is useful to diagnose vasospastic angina [12], [13]. MB is known to increase the risk of coronary vasospasm by endothelial dysfunction [14], [15], [16]. Furthermore, patients with MB were reported as being predisposed to severe and diffuse long coronary artery spasm [17]. However, MB has some anatomical and morphological variations, including location, length, depth, and degree of compression [2], [18], and the association between these variations of MB and vasospasm are not fully understood. Thus, the aim of this study was to investigate the relation between morphological severity of MB and coronary artery vasospasm induced by ACh provocation test.

Section snippets

Study population

From April 2012 to July 2016, a total of 446 patients underwent intracoronary ACh provocation test at Chiba University Hospital. Patients with ACh provocation only for the right coronary artery (RCA) (n = 3), and coronary stent in the LAD (n = 51), were excluded. Thus, 392 patients were included in the present study. Written informed consent for examination was obtained from all patients, and the ethical committee of Chiba University approved this study.

Intracoronary acetylcholine provocation test

Intracoronary ACh provocation tests were

Results

MBs were identified in 140 patients (36%) in the LAD, and 1 patient (0.3%) in the RCA and in the left circumflex, respectively. Table 1 lists baseline characteristics divided into 2 groups according to the presence of MB in the LAD. Patients with MB in the LAD had greater number of provoked vasospasm in the LAD, which most frequently occurred in the mid segment. Consequently, the rate of positive ACh provocation test was significantly higher in patients with MB compared to those without. On the

Discussion

More than one-third of patients undergoing intracoronary ACh provocation test with suspicion of vasospastic angina had MBs, which were mostly identified in the mid segment of the LAD. In the association between coronary spasm and MB, the new findings of this study are as follows: 1) patients with MB in the LAD were predisposed to cause coronary vasospasm in the segment proximal to MB or in the MB segment; and 2) there was a positive correlation in the morphological severity of MB assessed by

Conclusion

More than one-third of patients undergoing intracoronary ACh provocation test had MBs in the LAD. The existence of MB, especially the morphological severity of the MB, may have an association with occurrence of coronary vasospasm.

Conflicts of interest

None.

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Cited by (40)

Predicting the response to acetylcholine in ischemia or infarction with non-obstructive coronary arteries: The ABCD score
2024, Atherosclerosis
Acetylcholine (ACh) provocation testing can detect vasomotor disorders in patients with ischemia and non-obstructed coronary arteries (INOCA) or myocardial infarction and non-obstructed coronary arteries (MINOCA). We aimed to derive and validate a simple risk score to predict a positive ACh test response.
We prospectively enrolled consecutive INOCA and MINOCA patients undergoing ACh provocation testing. Patients were split in two cohorts (derivation and validation) according to time of enrolment. The score was derived in 386 patients (derivation cohort) and then validated in 165 patients (validation cohort).
551 patients were enrolled, 371 (67.3%) INOCA and 180 (32.7%) MINOCA. ACh test was positive in 288 (52.3%) patients. MINOCA, myocardial bridge (MB), C-reactive protein (CRP) and dyslipidaemia were independent predictors of a positive ACh test in the derivation cohort. The ABCD (Acute presentation, Bridge, CRP, Dyslipidaemia) score was derived: 2 points were assigned to MINOCA, 3 to MB, 1 to elevated CRP and 1 to dyslipidaemia. The ABCD score accurately identified patients with a positive ACh test response with an AUC of 0.703 (CI 95% 0.652–0.754,p < 0.001) in the derivation cohort, and 0.705 (CI 95% 0.626–0.784, p < 0.001) in the validation cohort. In the whole population, an ABCD score ≥4 portended 94.3% risk of a positive ACh test and all patients with an ABCD score ≥6 presented a positive test.
The ABCD score could avoid the need of ACh provocation testing in patients with a high score, reducing procedural risks, time, and costs, and allowing the implementation of a tailored treatment strategy. These results are hypothesis generating and further research involving larger cohorts and multicentre trials is needed to validate and refine the ABCD score.
Presence and Relevance of Myocardial Bridge in LAD-PCI of CTO and Non-CTO Lesions
2024, JACC: Cardiovascular Interventions
Intravascular ultrasound (IVUS) studies show that one-quarter of left anterior descending (LAD) arteries have a myocardial bridge. An MB may be associated with stent failure when the stent extends into the MB.
The aim of this study was to investigate: 1) the association between an MB and chronic total occlusion (CTO) in any LAD lesions; and 2) the association between an MB and subsequent clinical outcomes after percutaneous coronary intervention in LAD CTOs.
A total of 3,342 LAD lesions with IVUS-guided percutaneous coronary intervention (280 CTO and 3,062 non-CTO lesions) were included. The primary outcome was target lesion failure (cardiac death, target vessel myocardial infarction, definite stent thrombosis, and ischemic-driven target lesion revascularization).
An MB by IVUS was significantly more prevalent in LAD CTOs than LAD non-CTOs (40.4% [113/280] vs 25.8% [789/3,062]; P < 0.0001). The discrepancy in CTO length between angiography and IVUS was greater in 113 LAD CTOs with an MB than 167 LAD CTOs without an MB (6.0 [Q1, Q3: 0.1, 12.2] mm vs 0.2 [Q1, Q3: −1.4, 8.4] mm; P < 0.0001). Overall, 48.7% (55/113) of LAD CTOs had a stent that extended into an MB after which target lesion failure was significantly higher compared to a stent that did not extend into an MB (26.3% vs 0%; P = 0.0004) or compared to an LAD CTO without an MB (26.3% vs 9.6%; P = 0.02).
An MB was more common in LAD CTO than non-CTO LAD lesions. If present, approximately one-half of LAD CTOs had a stent extending into an MB that, in turn, was associated with worse outcomes.
Myocardial Infarction by a Myocardial Bridge in the LAD Combined With Atrioventricular Re-Entrant Supraventricular Tachycardia
2022, JACC: Case Reports
Citation Excerpt :
The most important trigger is sustained tachycardia caused by arrhythmias or extensive exercise in competitive athletes. In addition, there are also some reports in the literature of myocardial ischemia caused by coronary spasm in combination with a myocardial bridge.5 Multimodality imaging is essential for a comprehensive investigation of symptomatic patients with myocardial bridges.
We present the case of a patient who presented with palpitations and was found to have atrioventricular re-entrant tachycardia with unusually elevated cardiac biomarkers. A coronary computed tomographic angiography showed a myocardial left anterior descending artery bridge; an accessory pathway was ablated, and cardiac magnetic resonance revealed anteroseptal myocardial infarction resulting from hypoperfusion during tachycardia caused by the left anterior descending artery myocardial bridge. (Level of Difficulty: Intermediate.)
Morphological analysis of myocardial bridges and coronary arterial dominance in northeast Brazil
2022, Morphologie
Citation Excerpt :
There is also a codominant pattern, in which the blood supply of the posterior portion of the interventricular septum is shared by both right and left coronary arteries [2] Myocardial bridge (MB) is a congenital anomaly in which myocardial bundles cross or involve a portion of a coronary artery [3–5]. This results in a vascular compression and represents one of the main differential diagnosis for idiopathic chest pain, which may present itself as angina pectoris, acute coronary syndrome, heart arrythmia, and, more difficultly, acute myocardial infarction, or sudden death [2].
Coronary arterial dominance and myocardial bridges have clinical implications, since a left dominant pattern associated to the presence of myocardial bridges is often associated to a higher incidence of arteriosclerosis and higher mortality by myocardial infarction.
To determine the presence and position of myocardial bridges and their relation with coronary arterial dominance.
Fifty-seven human cadaveric hearts were analyzed into three groups, as follows: right dominance; left dominance; codominance. Each group was then divided into two subgroups: with or without myocardial bridges. Finally, each subgroup with myocardial bridges was classified according to the position of the myocardial bridge according to the main axis of the heart (proximal, middle and distal third).
The right dominance occurred in most hearts (30 hearts–52,6%). Twenty-three myocardial bridges (40,3%) were identified and mostly occurred on left dominant hearts (22,8%). The pattern of coronary dominance presented a statistically significant correlation with the presence of myocardial bridges (P = 0.048). The middle third of the heart axis showed the highest occurrence of myocardial bridges.
These findings suggest there is a clear relationship between the presence of myocardial bridges and left dominant pattern. Middle third of the heart axis present the higher occurrence of myocardial bridges. Knowledge of the myocardial bridges morphology is of great clinical significance, improving patient care.
La dominance artérielle coronaire et les ponts myocardiques ont des implications cliniques, puisqu’un cœur de dominance gauche associé à la présence de ponts myocardiques est souvent associé à une incidence plus élevée d’artériosclérose et une mortalité plus élevée par infarctus myocardique.
Déterminer la présence et la position des ponts myocardiques et leur relation avec la dominance artérielle coronaire.
Cinquante sept cœurs cadavériques humains ont été analysés en 3 groupes : dominance droite; dominance gauche; codominance. Chaque groupe a ensuite été divisé en 2 sous-groupes: avec et sans ponts myocardiques. Enfin, chaque sous-groupe avec des ponts myocardiques a été classé selon la hauteur du pont myocardique par rapport à l’axe principal du cœur (tiers proximal, moyen et distal).
La dominance droite s’est produit dans la plupart des cœurs (30 cœurs–52,6 %). Vingt-trois ponts myocardiques (40,3 %) ont été identifiés et se sont principalement produits sur les cœurs de dominance gauche (22,8 %). La dominance artérielle coronaire a une relation statistiquement significative avec la présence de ponts myocardiques (p = 0,048). Le tiers médian de l’axe cardiaque a montré la fréquence la plus élevée de ponts myocardiques.
Ces résultats suggèrent qu’il existe une relation claire entre la présence de ponts myocardiques et la dominance gauche. Le tiers médian de l’axe du cœur présente la fréquence plus élevée de ponts myocardiques. La connaissance de la morphologie des ponts myocardiques est d’une grande importance clinique, améliorant les soins aux patients.
Gender differences in factors associated with vasospastic angina
2022, International Journal of Cardiology
Citation Excerpt :
Epicardial coronary artery disease (CAD) was defined as ≥75% stenosis of the right, left anterior descending, or left circumflex coronary artery, or ≥ 50% stenosis of the left main trunk on coronary angiography [12]. Intracoronary ACh provocation tests were performed according to the guidelines [1,13], as we previously reported [14–19]. Briefly, all vasodilators such as calcium channel blockers and long-acting nitrates but short-acting sublingual nitroglycerin were discontinued at least 48 h before the ACh test in elective examinations.
Vasospastic angina (VSA) is reportedly associated with several clinical characteristics such as smoking and high-density lipoprotein (HDL) cholesterol, in which gender differences are present. For instance, smoking rates among men are higher than those among women, and a normal range of HDL cholesterol differs across genders. However, their impact between men and women on VSA is unclear.
A total of 797 patients (427 men and 370 women) undergoing intracoronary acetylcholine (ACh) provocation test to diagnose VSA were included. The positive ACh provocation test was defined as angiographic vasospasm accompanied by chest pain and/or ischemic electrocardiographic changes. Factors contributing to VSA across genders were evaluated by multivariable analyses.
Of 797 patients, 414 (51.9%) had positive ACh provocation test. The incidence of positive ACh test was higher in men than in women (56.9% vs. 46.2%, p = 0.003). In the entire study population, current smoking and a lower HDL cholesterol level were determined as factors associated with VSA. In both men and women, an HDL cholesterol level was identified as a factor contributing to positive ACh test.
Among patients suspected for VSA, men as compared with women were more likely to have positive ACh provocation test. While current smoking and an HDL cholesterol level were associated with VSA in the entire study population, a lower HDL cholesterol level was determined as the only factor contributing to positive ACh test across genders, suggesting that HDL cholesterol plays important roles in the mechanism of VSA.
Decreased Double Product at Rest in Patients With Severe Vasospasm
2020, Heart Lung and Circulation
Citation Excerpt :
Written informed consent for examination was obtained from all patients, and the ethical committee of Chiba University approved the study. Intracoronary ACh provocation tests were performed during a 3-day hospitalisation according to the Japanese Circulation Society Joint Working Group guidelines for diagnosis and treatment of patients with vasospastic angina by in clinical settings [12], as previously reported [15–18]. In brief, all vasodilators, such as calcium channel blockers and long-acting nitrates, were discontinued at least 48 hours before the examination, except for sublingual nitroglycerin as needed.
Autonomic nerve system and endothelial function play important roles in vasospastic angina. Elevated heart rate (HR), blood pressure (BP), and double product (DP) can increase endothelial-dependent coronary artery dilation and blood flow. However, the impact of HR, BP, and DP on occurrence and severity of VSA in the clinical setting is unclear.
A total of 170 patients undergoing intracoronary acetylcholine (ACh) provocation test during hospitalisation was included. Resting HR, BP, and DP were measured at least four times, and their variabilities were evaluated by standard deviations (SD) and coefficient of variations (CVs). Angiographic coronary artery vasospasm was defined as total or subtotal occlusion induced by ACh provocation.
Mean±SD HR (65.7±9.1 vs 69.6±7.9 beats per minute; p=0.003), systolic BP (122.3±13.4 vs 127.7±14.6 mmHg; p=0.01), and DP (8,001±1,229 vs 8,903±1,495; p<0.001) were significantly lower in patients with a positive ACh test than the counterpart, whereas SD and CV of both HR and systolic BP were not significantly different between the two groups. Mean HR, BP, and DP progressively decreased with increase in the number of vessels with angiographic vasospasm. Multivariate analysis showed current smoking and lower DP as independent predictors of the greater number of vessels with provoked angiographic vasospasm.
Resting HR, BP, and DP were lower in patients with vasospastic angina, especially in those with severe vasospasm.

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^☆: Statement of authorship: The authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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Relation between severity of myocardial bridge and vasospasm☆

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study population

Intracoronary acetylcholine provocation test

Results

Discussion

Conclusion

Conflicts of interest

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

Am. J. Cardiol.

Chest

J. Am. Coll. Cardiol.

Am. J. Cardiol.

Am. J. Cardiol.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

Int. J. Cardiol.

Significance of the anatomical properties of a myocardial bridge in coronary heart disease

Circ. J.

The effects of a myocardial bridge on coronary atherosclerosis and ischaemia

J. Pathol.

Myocardial bridges and ischemic heart disease

Eur. Heart J.

Systolic compression of the left anterior descending coronary artery: a case series, review of the literature, and therapeutic options including stenting

Catheter. Cardiovasc. Interv.

Anatomic properties of myocardial bridge predisposing to myocardial infarction

Circulation