Introduction
Methods
Study participants and protocol
Data collection on admission for the first CAG
Spasm provocation test (SPT) using intracoronary ergonovine injections
Statistical analysis
Results
Patient characteristics between the SPT group and non-SPT group
SPT group (n = 170) | Non-SPT group (n = 3170) | P value | |
---|---|---|---|
Age (year) | 59.3 ± 11.5 | 65.3 ± 11.1 | < 0.001 |
Male sex | 109 (64.1%) | 2409 (76.0%) | < 0.001 |
Body mass index (kg/m2) | 23.8 ± 3.5 | 24.3 ± 3.8 | 0.078 |
Smoking | 81 (47.6%) | 1567 (49.4%) | 0.650 |
Drinking | 94 (55.3%) | 1558 (49.1%) | 0.118 |
Hypertension | 84 (49.5%) | 2167 (68.4%) | < 0.001 |
Dyslipidemia | 68 (40.0%) | 1875 (59.1%) | < 0.001 |
Diabetes mellitus | 22 (12.9%) | 1085 (34.2%) | < 0.001 |
Hyperuricemia | 28 (16.5%) | 1035 (32.6%) | < 0.001 |
Chronic kidney disease | 66 (38.8%) | 2096 (66.1%) | < 0.001 |
History of PCI | 3 (1.8%) | 307 (9.7%) | < 0.001 |
History of CABG | 0 | 33 (1.0%) | 0.181 |
Atrial fibrillation | 9 (5.3%) | 289 (9.1%) | 0.089 |
NYHA ≥ II | 4 (2.4%) | 880 (27.8%) | < 0.001 |
Organic heart disease | 23 (13.5%) | 2402 (75.8%) | < 0.001 |
Ischemic heart disease | 13 (7.6%) | 1864 (58.8%) | < 0.001 |
Valvular disease | 8 (4.7%) | 543 (17.1%) | < 0.001 |
Cardiomyopathy | 2 (1.2%) | 337 (10.6%) | < 0.001 |
Congenital heart disease | 1 (0.6%) | 20 (0.6%) | 0.945 |
Laboratory data | |||
Creatinine (mg/dl) | 0.8 ± 0.2 | 1.1 ± 1.3 | 0.001 |
eGFR (ml/min/1.73 m2) | 65.1 ± 16.5 | 53.1 ± 17.6 | < 0.001 |
Uric acid (mg/dl) | 5.4 ± 1.2 | 5.8 ± 1.5 | 0.001 |
LDL cholesterol (mg/dl) | 112.1 ± 29.9 | 109.8 ± 32.2 | 0.398 |
HbA1c (NGSP) (%) | 5.8 ± 0.7 | 6.2 ± 1.0 | < 0.001 |
Medication at discharge | |||
Antihypertensive agents | 76 (44.7%) | 2170 (68.5%) | < 0.001 |
Beta blockers | 15 (8.8%) | 1081 (34.1%) | < 0.001 |
Calcium channel blockers | 84 (49.4%) | 1351 (42.6%) | 0.081 |
Renin–angiotensin system inhibitors | 28 (16.5%) | 1476 (46.6%) | < 0.001 |
Antiplatelets | 37 (21.8%) | 1662 (52.4%) | < 0.001 |
Anticoagulants | 7 (4.1%) | 430 (13.6%) | < 0.001 |
Diuretics | 1 (0.6%) | 294 (9.3%) | < 0.001 |
Echocardiographic data | |||
Interventricular septum thickness (mm) | 9.5 ± 1.6 | 10.5 ± 2.1 | < 0.001 |
Left ventricular diameter at end- diastole (mm) | 45.7 ± 4.5 | 47.7 ± 7.0 | < 0.001 |
Left ventricular ejection fraction (%) | 68.5 ± 6.4 | 62.6 ± 13.4 | < 0.001 |
Left atrial dimension (mm) | 35.1 ± 6.1 | 38.2 ± 7.4 | < 0.001 |
E/e' | 9.5 ± 3.1 | 12.4 ± 5.4 | 0.010 |
Location of MB | |||
Proximal LAD | 0 | 0 | – |
Mid-LAD | 23 (13.5%) | 220 (6.9%) | 0.001 |
Distal LAD | 0 | 18 (0.6%) | 0.325 |
Posterior descending branch (#4PD) | 0 | 1 (0.03%) | 0.817 |
Atrioventricular branch (#4AV) | 0 | 1 (0.03%) | 0.817 |
High lateral branch | 0 | 1 (0.03%) | 0.817 |
Patient characteristics between the patients with and without MB
MB (+) group (n = 23) | MB (−) group (n = 143) | P value | |
---|---|---|---|
Age (year) | 58.5 ± 11.8 | 59.3 ± 11.5 | 0.779 |
Male sex | 16 (69.6%) | 89 (62.2%) | 0.499 |
Symptoms (Chest pain or chest discomfort) | All | all | – |
Body mass index (kg/m2) | 23.9 ± 4.3 | 23.7 ± 3.3 | 0.794 |
Smoking | 10 (43.5%) | 67 (46.9%) | 0.763 |
Drinking | 10 (43.5%) | 81 (56.6%) | 0.239 |
Hypertension | 9 (39.1%) | 72 (50.3%) | 0.318 |
Dyslipidemia | 11 (47.8%) | 54 (37.8%) | 0.359 |
Diabetes mellitus | 6 (26.1%) | 14 (9.8%) | 0.026 |
Hyperuricemia | 5 (21.7%) | 21 (14.7%) | 0.388 |
Chronic kidney disease | 14 (60.9%) | 51 (35.7%) | 0.022 |
Laboratory data | |||
Creatinine (mg/dl) | 0.8 ± 0.2 | 0.7 ± 0.2 | 0.432 |
eGFR (ml/min/1.73 m2) | 63.5 ± 18.9 | 65.3 ± 16.3 | 0.621 |
Uric acid (mg/dl) | 5.7 ± 1.4 | 5.4 ± 1.2 | 0.331 |
LDL cholesterol (mg/dl) | 112.8 ± 27.5 | 111.9 ± 30.1 | 0.900 |
HbA1c (NGSP) (%) | 6.1 ± 0.9 | 5.8 ± 0.6 | 0.139 |
Medication at discharge | |||
Antihypertensive agents | 10 (43.5%) | 63 (44.1%) | 0.959 |
Beta blockers | 2 (8.7%) | 12 (8.4%) | 0.961 |
Calcium channel blockers | 12 (52.2%) | 69 (48.3%) | 0.727 |
Renin–angiotensin system inhibitors | 4 (17.4%) | 21 (14.7%) | 0.736 |
Antiplatelets | 2 (8.7%) | 33 (23.1%) | 0.117 |
Anticoagulants | 1 (4.3%) | 6 (4.2%) | 0.973 |
Echocardiographic parameters | |||
Interventricular septum thickness (mm) | 10.2 ± 1.9 | 9.3 ± 1.5 | 0.018 |
Left ventricular diameter at end-diastole (mm) | 45.1 ± 4.9 | 45.7 ± 4.4 | 0.625 |
Left ventricular ejection fraction (%) | 70.9 ± 7.7 | 68.1 ± 6.1 | 0.066 |
Left atrial dimension (mm) | 36.1 ± 5.9 | 34.9 ± 6.1 | 0.421 |
E/e' | 8.3 ± 1.5 | 9.8 ± 3.2 | 0.378 |
Association between the presence of MB and SPT
MB (+) group (n = 23) | MB (−) group (n = 143) | P value | |
---|---|---|---|
SPT-positivity | 13 (56.5%) | 32 (22.4%) | 0.001 |
Signs of ischemia | |||
ECG changes | 13 (56.5%) | 32 (22.4%) | 0.001 |
Chest symptoms | 15 (65.2%) | 42 (29.4%) | 0.001 |
Tested coronary arteries | |||
RCA | 17 (73.9%) | 127 (88.8%) | 0.050 |
LCA | 23 (100%) | 143 (100%) | – |
Both RCA and LCA | 17 (73.9%) | 127 (88.8%) | 0.050 |
Culprit vessel of SPT-positivity | |||
RCA | 7 (30.4%) | 16 (11.2%) | 0.013 |
LAD | 8 (34.8%) | 11 (7.7%) | < 0.001 |
LCX | 1 (4.3%) | 8 (5.6%) | 0.806 |
Multivessel spasm | 2 (8.7%) | 3 (2.1%) | 0.086 |
Variable | Univariate model | Multivariate modela | ||||
---|---|---|---|---|---|---|
Odds ratio | 95% CI | P value | Odds ratio | 95% CI | P value | |
MB (+) | 4.509 | 1.809–11.241 | 0.001 | 5.587 | 2.061–15.149 | 0.001 |
Age | 1.001 | 0.972–1.032 | 0.937 | |||
Male | 3.605 | 1.549–8.387 | 0.003 | 3.798 | 1.557–9.266 | 0.003 |
Smoking | 1.659 | 0.832–3.305 | 0.150 | |||
Drinking | 1.516 | 0.753–3.054 | 0.244 | |||
Hypertension | 2.113 | 1.048–4.262 | 0.037 | 2.637 | 1.214–5.729 | 0.014 |
Diabetes mellitus | 1.530 | 0.568–4.120 | 0.400 | |||
Dyslipidemia | 1.191 | 0.594–2.390 | 0.622 | |||
Chronic kidney disease | 2.230 | 1.112–4.474 | 0.024 | |||
Hyperuricemia | 2.779 | 1.171–6.595 | 0.020 |
Discussion
Major findings
Frequency and positivity rate of SPT compared with the previous reports
Definition of MB | Definition of SPT-positivity | SPT-positivity rate | Provocation drugs | Prevalence of MB (%) | |||
---|---|---|---|---|---|---|---|
All (%) | MB (+) group (%) | MB (−) group (%) | |||||
Arai et al | Angiographic reduction in the diameter of the coronary artery during systole, also known as the “milking effect” between systole and diastole | Total or subtotal occlusion with ECG changes and/or chest pain | 27.1 | 56.5 | 22.4 | ER | 13.9 |
Teragawa et al. [8] | Angiographic reduction in the diameter of the coronary artery during systole of > 15% | ≥ 50% reduction in the arterial diameter, associated with ECG changes and/or chest pain | 51.8 | 73.2 | 39.7 | ACH and ER | 36.0 |
Saito et al. [12] |
Angiographic systolic narrowing of coronary vessels that was pronounced than in neighboring normal vessels, with partial or complete decompression during diastole (i.e. milking effect) | Total or subtotal occlusion with ECG changes and/or chest pain | 49.0 | 59.3 | 43.3 | ACH | 35.7 |
Xiang et al. [19] | 50% angiographic reduction in the diameter of the coronary artery during systole | 90% or above reduction in the arterial diameter with ECG changes and/or chest pain | 63.4 | 85.3 | 53.4 | ACH | 31.5 |