This project is supported in part by grant KKF-15-1.

NOTA: La prueba de la acetilcolina intracoronaria ha sido aprobado por el comité de ética local y el protocolo sigue las directrices de nuestra institución para la investigación humana. 1. Preparación de las Soluciones de acetilcolina (ver Materiales Tabla) <ol><li> Mezclar el 20 mg de acetilcolina con los 2 ml del disolvente se obtienen con el paquete. </li><li> Añadir la solución de ACH 2 ml a 98 ml de NaCl 0,9%. Esto corresponde a una dosis de 0,2 mg / ml y se llama solución de reserva 1. Añadir 9 ml de solución madre de 1 a 91 ml de NaCl 0,9%, esto corresponde a una dosis de 18 mg / ml y se llama de la solución 2. </li><li> Preparar 3 jeringas de perfusión (cada una de 50 ml) etiquetados como &quot;alto&quot;, &quot;medio&quot; y &quot;bajo&quot;. Llene la jeringa de perfusión 1 etiqueta &quot;alta&quot; con 40 ml de solución madre 2. </li><li> Llene la jeringa de perfusión 2 (con la etiqueta &quot;medio&quot;) con 8 ml de la jeringa de perfusión 1 (alto) y añadir 32 ml de NaCl al 0,9%. Esto corresponde a unadosis de 3,6 mg / ml. </li><li> Llene la jeringa de perfusión 3 (con la etiqueta &quot;bajo&quot;) con 4 ml de la jeringa de perfusión 2 (medio) y añadir 36 ml de NaCl al 0,9%. Esto corresponde a una dosis de 0,36 g / ml. </li></ol> 2. Preparación de las jeringas para la inyección intracoronaria de acetilcolina <ol><li> Preparar 5 jeringas para la inyección intracoronaria (4 jeringas de 5 ml [# 1, # 2, # 3, # 4] y 1 jeringa de 10 ml). </li><li> Llene la jeringa de 5 ml # 1 con 6 ml de la jeringa de perfusión con la etiqueta &quot;baja&quot; (véase el paso 1.5). Esto corresponde a una dosis de aproximadamente 2 mg. </li><li> Llene la jeringa de 5 ml # 2 con 6 ml de la jeringa de perfusión con la etiqueta &quot;medio&quot;. Esto corresponde a una dosis de aproximadamente 20 mg. </li><li> Llene la jeringa de 5 ml # 3 con 5,5 ml de la jeringa de perfusión con la etiqueta &quot;alta&quot;. Esto corresponde a una dosis de aproximadamente 100 mg. </li><li> Llene la jeringa de 10 ml con 11 ml de la jeringa de perfusión marcado4;. Alta &quot;Esto corresponde a una dosis de aproximadamente 200 mg. </li><li> Llene la jeringa de 5 ml # 4 con 4,5 ml de la jeringa de perfusión con la etiqueta &quot;alta&quot;. Esto corresponde a una dosis de aproximadamente 80 mg. Ponga esta jeringa a un lado y sólo lo utilizan para la evaluación de la arteria coronaria derecha. </li></ol> 3. Diagnóstico angiografía coronaria <ol><li> Inyectar anestesia local o bien en la proximidad de la arteria radial derecha (generalmente de 2 ml de mepivacaína) o en la proximidad de la arteria femoral derecha (normalmente 15 ml de mepivacaína). </li><li> Para confirmar el éxito de la anestesia local es mediante un pinchazo en la piel anestesiada con la aguja y preguntando al paciente si el dolor aún está presente. </li><li> La punción de la arteria, según la técnica de Seldinger 13 con una cánula, a continuación, insertar el cable a través de la cánula y retirarla. Inserte la vaina (generalmente 5F) sobre el alambre. Realizar la angiografía coronaria en condiciones estériles. </li><li> Avanzar en el th del alambreáspera la vaina a la aorta ascendente y colocar el catéter de diagnóstico por encima de la válvula aórtica. A continuación, retire el cable y conectar el catéter con la jeringa contraste. NOTA: El agente de contraste contiene Iomeprol, trometamol, ácido clorhídrico y agua. </li><li> Coloque el catéter de diagnóstico para la arteria coronaria izquierda en el tronco principal izquierdo estirando un poco y girando el catéter. Confirmar la colocación correcta del catéter mediante la inyección de 2 ml de agente de contraste. </li><li> Realizar la angiografía coronaria de acuerdo con la técnica de Judkins 14 con inyecciones manuales de aproximadamente 10 ml de contraste para visualizar las arterias coronarias en los diferentes puntos de vista. NOTA: Por lo general LAO 40 ° y 35 ° RAO se utilizan para la arteria coronaria derecha y LAO 45 ° / 25 ° CRAN, RAO 30 ° / 30 ° CRAN y RAO 20 ° / 30 ° CAUD se utilizan para la arteria coronaria izquierda. </li><li> Comenzar las pruebas de acetilcolina después de la exclusión de cualquier estenosis epicárdica relevante (≥50%) Por evaluación visual. </li></ol> 4. La inyección intracoronaria de acetilcolina <ol><li> Inyectar 6 ml de la 2 g jeringa # 1 en la arteria coronaria izquierda. Inyectar esto dentro de 20 segundos, con monitorización continua del ECG y los síntomas del paciente (por ejemplo, dolor en el pecho, dificultad para respirar, mareos). Realizar la angiografía coronaria de la arteria coronaria izquierda (por lo general una proyección RAO 20 ° / 30 ° CAUD es mejor proyección) después de la inyección de los 6 ml. </li><li> Realizar la angiografía coronaria mediante la inyección de 10 ml de contraste manualmente a través de la jeringa de contraste en el catéter. El 12 derivaciones ECG debe ser registrada y se imprime después de cada dosis de acetilcolina. Una pausa de 1 minuto debe estar entre cada dosis. </li><li> Inyectar 6 ml de la 20 g jeringa # 2 en la arteria coronaria izquierda. Inyectar esto dentro de 20 segundos con un seguimiento continuo del ECG y los síntomas del paciente. Realizar la angiografía coronaria de la arteria coronaria izquierda después de la inyecciónde los 6 ml como se mencionó anteriormente. </li><li> Inyectar 5,5 ml de la 100 g jeringa # 3 en la arteria coronaria izquierda. Inyectar esto dentro de 20 segundos con un seguimiento continuo del ECG y los síntomas del paciente. Realizar la angiografía coronaria de la arteria coronaria izquierda después de la inyección de los 5,5 ml como se mencionó anteriormente. NOTA: La mayoría de los pacientes reportan algunos síntomas, muestran cambios en el ECG o vasoconstricción epicárdica a esta dosis. A veces la velocidad de la inyección manual debe ser ralentizado. Como se menciona más adelante diferentes protocolos para la ACH-prueba están en uso con una velocidad diferente de la inyección. Una inyección más lenta durante un período de 3 min en comparación con la inyección dentro de 20 seg también puede ser factible. </li><li> Si no espasmo (es decir,&gt; 90% vasoconstricción en comparación con el estado de relajación del vaso después de la inyección 200 mg nitroglyercine) se produce en la dosis de 100 mg continuar con la dosis ACH 200 g (10 ml jeringa). Inyectar los 11 ml en 20 segundos con monitor continuoING del ECG y los síntomas del paciente. </li><li> Realizar la angiografía coronaria de la arteria coronaria izquierda después de la inyección de los 11 ml como se mencionó anteriormente (sección 3). NOTA: Si bien la dosis de 200 mg se ha aplicado en muchos pacientes se debe mencionar que las dosis apropiadas de acetilcolina intracoronaria aún no se han definido completamente. Algunos autores sugieren que 100 mg debe ser la dosis máxima de la arteria coronaria izquierda. NOTA: A menudo se produce bradicardia y la velocidad de la inyección debe ser ralentizado. </li><li> Inyectar 80 g de ACH (4,5 ml, jeringa # 4) en la arteria coronaria derecha, si no se observan hallazgos anormales durante las pruebas de la arteria coronaria izquierda. Inyectar esto dentro de 20 segundos con un seguimiento continuo del ECG y los síntomas del paciente. A menudo se produce bradicardia y la velocidad de la inyección debe ser desacelerado para evitar la bradicardia y / o asistolia prolongada. </li><li> Realizar la angiografía coronaria de la arteria coronaria derechadespués de la inyección de los 4,5 ml (por lo general una proyección OAI 40 ° / 0 ° es el mejor) como se ha mencionado anteriormente (sección 3). </li><li> Inyectar la nitroglicerina intracoronaria con una dosis de 200 mg en cada arteria prueba después de la prueba o cuando los síntomas graves (es decir, dolor severo en el pecho o dificultad respiratoria grave), los cambios isquémicos en el ECG o espasmo del epicardio se produce. </li><li> La imagen del vaso como se menciona en el paso 4.2 después de un minuto para documentar la reversión del espasmo. </li></ol>

<ol>
	<li>Prinzmetal, M., Kennamer, R., Merliss, R., Wada, T., Bor, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Angina+pectoris.+I.+A+variant+form+of+angina+pectoris;+preliminary+report.">Angina pectoris. I. A variant form of angina pectoris; preliminary report.</a> Am J Med. 27, 375-388 (1959).</li><li>Cheng, T. O., Bashour, T., Kelser, G. A., Weiss, L., Bacos, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Variant+angina+of+Prinzmetal+with+normal+coronary+arteriograms.+A+variant+of+the+variant.">Variant angina of Prinzmetal with normal coronary arteriograms. A variant of the variant.</a> Circulation. 47 (3), 476-485 (1973).</li><li>Yasue, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Induction+of+coronary+artery+spasm+by+acetylcholine+in+patients+with+variant+angina:+possible+role+of+the+parasympathetic+nervous+system+in+the+pathogenesis+of+coronary+artery+spasm.">Induction of coronary artery spasm by acetylcholine in patients with variant angina: possible role of the parasympathetic nervous system in the pathogenesis of coronary artery spasm.</a> Circulation. 74 (5), 955-963 (1986).</li><li>Bell, M. R., Berger, P. B., Holmes, D. R., Mullany, C. J., Bailey, K. R., Gersh, B. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Referral+for+coronary+artery+revascularization+procedures+after+diagnostic+coronary+angiography:+evidence+for+gender+bias?.">Referral for coronary artery revascularization procedures after diagnostic coronary angiography: evidence for gender bias?.</a> J Am Coll Cardiol. 25 (7), 1650-1655 (1995).</li><li>Patel, M. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Low+diagnostic+yield+of+elective+coronary+angiography.">Low diagnostic yield of elective coronary angiography.</a> N Engl J Med. 362 (10), 885-895 (2010).</li><li>Pocock, S. J., Henderson, R. A., Seed, P., Treasure, T., Hampton, J. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quality+of+life,+employment+status,+and+anginal+symptoms+after+coronary+angioplasty+or+bypass+surgery.+3-year+follow-up+in+the+Randomized+Intervention+Treatment+of+Angina.">Quality of life, employment status, and anginal symptoms after coronary angioplasty or bypass surgery. 3-year follow-up in the Randomized Intervention Treatment of Angina.</a> Circulation. 94 (2), 135-142 (1996).</li><li>Ong, P., Athanasiadis, A., Borgulya, G., Mahrholdt, H., Kaski, J. C., Sechtem, U. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=High+prevalence+of+a+pathological+response+to+acetylcholine+testing+in+patients+with+stable+angina+pectoris+and+unobstructed+coronary+arteries.+The+ACOVA+Study+(Abnormal+COronary+VAsomotion+in+patients+with+stable+angina+and+unobstructed+coronary+arteries).">High prevalence of a pathological response to acetylcholine testing in patients with stable angina pectoris and unobstructed coronary arteries. The ACOVA Study (Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries).</a> J Am Coll Cardiol. 59 (7), 655-662 (2012).</li><li>Furchgott, R. F., Zawadzki, J. V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+obligatory+role+of+endothelial+cells+in+the+relaxation+of+arterial+smooth+muscle+by+acetylcholine.">The obligatory role of endothelial cells in the relaxation of arterial smooth muscle by acetylcholine.</a> Nature. 288 (5789), 373-376 (1980).</li><li>Shimizu, H., Lee, J. D., Ogawa, K., Hara, A., Nakamura, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Coronary+artery+vasoreactivity+to+intracoronary+acetylcholine+infusion+test+in+patients+with+chest+pain+syndrome.">Coronary artery vasoreactivity to intracoronary acetylcholine infusion test in patients with chest pain syndrome.</a> Intern Med. 31 (1), 22-27 (1992).</li><li>Montalescot, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=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.">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.</a> Eur Heart J. 34 (38), 2949-3003 (2013).</li><li>JCS Joint Working Group. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+for+diagnosis+and+treatment+of+patients+with+vasospastic+angina+(Coronary+Spastic+Angina)+(JCS+2013).">Guidelines for diagnosis and treatment of patients with vasospastic angina (Coronary Spastic Angina) (JCS 2013).</a> Circ J. 78 (11), 2779-2801 (2014).</li><li>Ong, P., Athanasiadis, A., Sechtem, U. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patterns+of+coronary+vasomotor+responses+to+intracoronary+acetylcholine+provocation.">Patterns of coronary vasomotor responses to intracoronary acetylcholine provocation.</a> Heart. 99 (17), 1288-1295 (2013).</li><li>Seldinger, S. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Catheter+replacement+of+the+needle+in+percutaneous+arteriography;+a+new+technique.">Catheter replacement of the needle in percutaneous arteriography; a new technique.</a> Acta radiol. 39 (5), 368-376 (1953).</li><li>Judkins, M. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Selective+coronary+arteriography.+I.+A+percutaneous+transfemoral+technic.">Selective coronary arteriography. I. A percutaneous transfemoral technic.</a> Radiology. 89 (5), 815-824 (1967).</li><li>Mohri, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Angina+pectoris+caused+by+coronary+microvascular+spasm.">Angina pectoris caused by coronary microvascular spasm.</a> Lancet. 351 (9110), 1165-1169 (1998).</li><li>Chandrasekar, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complications+of+cardiac+catheterization+in+the+current+era:+a+single-center+experience.">Complications of cardiac catheterization in the current era: a single-center experience.</a> Catheter Cardiovasc Interv. 52, 289-295 (2001).</li><li>Nakao, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hyperventilation+as+a+specific+test+for+diagnosis+of+coronary+artery+spasm.">Hyperventilation as a specific test for diagnosis of coronary artery spasm.</a> Am J Cardiol. 80 (5), 545-549 (1997).</li></ol>

The authors have nothing to disclose.

Es factible aplicar la prueba de la acetilcolina en la rutina clínica diaria en el laboratorio de cateterismo. Además de la preparación de las soluciones de ACH hay varias cuestiones técnicas que tienen que ser resueltos antes de comenzar la prueba incluyendo ECG conduce radiotransparente para el registro continuo del ECG de 12 derivaciones. Esto es esencial para ser capaz de detectar cambios en el ECG isquémicos transitorios durante la prueba. Además, es importante saber que las soluciones de ACH sólo se pueden ...

La angina de pecho es la característica de la enfermedad de la arteria coronaria y el concepto de una estenosis epicárdica causando isquemia de miocardio y la angina inducida por el ejercicio se ha establecido durante muchos años. Sin embargo, muchos pacientes con angina de pecho no tienen la tríada típica de dolor retroesternal, aparición durante el ejercicio y el alivio por la nitroglicerina o de descanso. Con frecuencia los pacientes informan de la angina de pecho en reposo o una combinación de angina de esfuerzo y descanso, así como falta de aliento cuando hace algún esfuerzo como un posible equivalente angina de pecho. En 1959 Prinzmetal fue el primero en introducir el concepto de espasmo transitoria de las arterias coronarias que causan la angina en reposo asociado con elevación del segmento ST en el electrocardiograma (ECG), pero con la capacidad de ejercicio conservado 1. Esta hipótesis fue confirmada más tarde mediante la angiografía coronaria y parecía que el espasmo coronario puede estar presente en los pacientes con estenosis epicárdicas o arterias coronarias normales 2. En el 1980ies una provocación acetilcolina intracoronaria pruebas (ACH-test) para la detección de espasmo de la arteria coronaria se estableció en Japón y, posteriormente, el interés en la investigación clínica para el espasmo coronario aumentó 3. Sin embargo, después de la introducción de la intervención coronaria percutánea en 1977 y la primera implantación del stent en 1986 el interés en los trastornos vasomotores coronarias se redujo considerablemente, al menos en Europa y Estados Unidos. Esto puede ser también debido a la naturaleza invasiva de la ACH-test (debido a la corta vida media de ACH que sólo se puede administrar en las arterias coronarias para la evaluación de espasmo coronario). Sin embargo, muchos pacientes con signos y síntomas de isquemia miocárdica no tienen ninguna estenosis epicárdica pertinente sobre 4,5,6 angiografía coronaria. En estos pacientes las pruebas de provocación acetilcolina intracoronaria es útil para detectar un trastorno vasomotor coronaria clínicamente relevante y el tratamiento médico adecuado <sup&gt; 7. La acetilcolina es un neurotransmisor en el sistema nervioso parasimpático. Actúa a través de nicotinérgico, así como los receptores muscarinérgicos (mAChR). Estos últimos son importantes para la homeostasis vascular y la acetilcolina se une en mAChR como un agonista no selectivo. La activación de estos receptores a nivel endotelial conduce a la vasodilatación mediada por óxido nítrico mientras que la activación de mAChR sobre las células del músculo liso vascular conduce a la vasoconstricción 8. Dependiendo de la integridad del endotelio y la reactividad de las células musculares lisas, el efecto neto de la administración de acetilcolina intracoronaria es la vasodilatación o vasoconstricción. La respuesta fisiológica de las arterias coronarias en respuesta a la acetilcolina en los seres humanos no se entiende completamente pero se ha informado de que la vasodilatación, así como la vasoconstricción de hasta 25% del diámetro de los vasos pueden ser fisiológica como se muestra en los pacientes con arterias coronarias normales y no pec la angina de pechoToris 9. Pruebas de provocación acetilcolina intracoronaria ha sido recomendado por la Sociedad Europea de Cardiología 10, así como las guías de la Sociedad Japonesa de circulación 11 para la evaluación del epicardio y / o espasmo microvascular en pacientes con angina de pecho y las arterias coronarias obstruidas. Pruebas de provocación acetilcolina intracoronaria se ha establecido en la rutina clínica diaria en el laboratorio de cateterización de nuestra institución en el año 2003. Desde el año 2006 un protocolo estandarizado se ha seguido 12. ACH-prueba se realiza generalmente en todos los pacientes con signos y síntomas de isquemia miocárdica aún sin estenosis epicárdica relevante (&lt;50%) en la angiografía coronaria. ACH-prueba se realiza inmediatamente después de la angiografía coronaria de diagnóstico de acuerdo con el protocolo descrito a continuación. Ergonovine es otro agente que se utiliza para la prueba de espasmo provocación con un mecanismo de acción diferente. Detalladoinformación sobre las pruebas ergonovina se puede encontrar en otro lugar 12.

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		<tr height="21">
			<td height="21" style="height:21px;width:528px;">Vial of 20 mg acetylcholine chloride powder and 1 Ampoule of 2 mL diluent</td>
			<td style="width:151px;">Bausch &#38; Lomb&#160;</td>
			<td style="width:165px;">NDC 24 208-539-20</td>
			<td style="width:80px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">3 x 100 ml NaCl 0.9 %</td>
			<td>BBraun</td>
			<td>3200950</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">3 x syringe 50 ml each</td>
			<td>BBraun</td>
			<td>4187903</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">&#160;1 x 2 ml syringe</td>
			<td>BBraun</td>
			<td>4606027V</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">&#160;1 x 10 ml syringe</td>
			<td>BBraun</td>
			<td>4606108V</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">2 x cannula 20 G 70mm</td>
			<td>BBraun</td>
			<td>4665791</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">&#160;5 x 5 ml syringe</td>
			<td>BBraun</td>
			<td>4606051V</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Contrast agent Imeron 350 with a 10ml syringe for contrast injection</td>
			<td>Bracco Imaging</td>
			<td>30699.03.00</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Coronary angiography suite (AXIOM Artis MP eco )</td>
			<td>Siemens</td>
			<td>n/a</td>
			<td></td>
		</tr>
	</tbody>
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intracoronary acetylcholine provocation testing for assessment of coronary vasomotor disorders

Intracoronary acetylcholine provocation testing (ACH-test) is an established method for assessment of epicardial coronary artery spasm in the catheterization laboratory which was introduced more than 30 years ago. Due to the short half-life of acetylcholine it can only be applied directly into the coronary arteries. Several studies have demonstrated the safety and clinical usefulness of this test. However, acetylcholine testing is only rarely applied in the U.S. or Europe. Nevertheless, it has been shown that 62% of Caucasian patients with stable angina and unobstructed coronary arteries on coronary angiography suffer from coronary vasomotor disorders that can be diagnosed with acetylcholine testing. In recent years it has been appreciated that the ACH-test not only assesses the presence of epicardial spasm but that it can also be useful for the detection of coronary microvascular spam. In such cases no epicardial spasm is seen after injection of acetylcholine but ischemic ECG shifts are present together with a reproduction of the patient's symptoms during the test. This article describes the experience with the ACH-test and its implementation in daily clinical routine.

Interpretación de la prueba acetilcolina se basa en tres criterios. En primer lugar, se le pide al paciente durante todo el ensayo se encuentren o no de síntomas. Con frecuencia, los pacientes refieren una reproducción de sus síntomas habituales, tales como dolor en el pecho, dificultad para respirar u otros síntomas. Esto representa un punto importante para la interpretación global de la prueba. En segundo lugar, un registro de 12 derivaciones ECG se realiza de forma continua dura...

Watch this Scientific Journal Video about Intracoronary Acetylcholine Provocation Testing for Assessment of Coronary Vasomotor Disorders at JoVE.com

Intracoronary Acetylcholine Provocation Testing for Assessment of Coronary Vasomotor Disorders

Intracoronary acetylcholine testing has been established for the assessment of epicardial coronary spasm more than 30 years ago. Recently, the focus has shifted towards the microcirculation and it has been shown that microvascular spasm can be detected using ACH-testing. This article describes the ACH-test and its implementation in daily routine.

Intracoronaria de acetilcolina pruebas de provocación para la evaluación de los trastornos vasomotores coronaria

Intracoronary acetylcholine provocation testing (ACH-test) is an established method for assessment of epicardial coronary artery spasm in the ...

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JoVE Journal

Medicine

15.5K vistas.  Robert-Bosch-Krankenhaus. Intracoronary acetylcholine testing has been established for the assessment of epicardial coronary spasm more than 30 years ago. Recently, the focus has shifted towards the microcirculation and it has been shown that microvascular spasm can be detected using ACH-testing. This article describes the ACH-test and its implementation in daily routine.

Video: Intracoronary Acetylcholine Provocation Testing for Assessment of Coronary Vasomotor Disorders

A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis (ALS)

Improved methods for assessing bulbar impairment are necessary for expediting diagnosis of bulbar dysfunction in ALS, for predicting disease progression across speech subsystems, and for addressing the critical need for sensitive outcome measures for ongoing experimental treatment trials. To address this need, we are obtaining longitudinal profiles of bulbar impairment in 100 individuals based on a comprehensive instrumentation-based assessment that yield objective measures. Using instrumental approaches to quantify speech-related behaviors is very important in a field that has primarily relied on subjective, auditory-perceptual forms of speech assessment1. Our assessment protocol measures performance across all of the speech subsystems, which include respiratory, phonatory (laryngeal), resonatory (velopharyngeal), and articulatory. The articulatory subsystem is divided into the facial components (jaw and lip), and the tongue. Prior research has suggested that each speech subsystem responds differently to neurological diseases such as ALS. The current protocol is designed to test the performance of each speech subsystem as independently from other subsystems as possible. The speech subsystems are evaluated in the context of more global changes to speech performance. These speech system level variables include speaking rate and intelligibility of speech.
The protocol requires specialized instrumentation, and commercial and custom software. The respiratory, phonatory, and resonatory subsystems are evaluated using pressure-flow (aerodynamic) and acoustic methods. The articulatory subsystem is assessed using 3D motion tracking techniques. The objective measures that are used to quantify bulbar impairment have been well established in the speech literature and show sensitivity to changes in bulbar function with disease progression. The result of the assessment is a comprehensive, across-subsystem performance profile for each participant. The profile, when compared to the same measures obtained from healthy controls, is used for diagnostic purposes. Currently, we are testing the sensitivity and specificity of these measures for diagnosis of ALS and for predicting the rate of disease progression. In the long term, the more refined endophenotype of bulbar ALS derived from this work is expected to strengthen future efforts to identify the genetic loci of ALS and improve diagnostic and treatment specificity of the disease as a whole. The objective assessment that is demonstrated in this video may be used to assess a broad range of speech motor impairments, including those related to stroke, traumatic brain injury, multiple sclerosis, and Parkinson disease.

A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis ALS

Objective assessments of the physiological mechanisms that support speech are needed to monitor disease onset and progression in persons with ALS and to quantify treatment effects in clinical trials. In this video, we present a comprehensive, instrumentation-based protocol for quantifying speech motor performance in clinical populations.

Un Protocolo de Evaluación Integral de la disfunción bulbar de la Esclerosis Lateral Amiotrófica (ALS)

Improved methods for assessing bulbar impairment are necessary for expediting diagnosis of bulbar dysfunction in ALS, for predicting disease progression ...

Investigación

Medicina

Use of a Hanging Weight System for Coronary Artery Occlusion in Mice

Murine studies of acute injury are an area of intense investigation, as knockout mice for different genes are becoming increasingly available 1-38. Cardioprotection by ischemic preconditioning (IP) remains an area of intense investigation. To further elucidate its molecular basis, the use of knockout mouse studies is particularly important 7, 14, 30, 39. Despite the fact that previous studies have already successfully performed cardiac ischemia and reperfusion in mice, this model is technically very challenging. Particularly, visual identification of the coronary artery, placement of the suture around the vessel and coronary occlusion by tying off the vessel with a supported knot is technically difficult. In addition, re-opening the knot for intermittent reperfusion of the coronary artery during IP without causing surgical trauma adds additional challenge. Moreover, if the knot is not tied down strong enough, inadvertent reperfusion due to imperfect occlusion of the coronary may affect the results. In fact, this can easily occur due to the movement of the beating heart.
Based on potential problems associated with using a knotted coronary occlusion system, we adopted a previously published model of chronic cardiomyopathy based on a hanging weight system for intermittent coronary artery occlusion during IP 39. In fact, coronary artery occlusion can thus be achieved without having to occlude the coronary by a knot. Moreover, reperfusion of the vessel can be easily achieved by supporting the hanging weights which are in a remote localization from cardiac tissues.
We tested this system systematically, including variation of ischemia and reperfusion times, preconditioning regiments, body temperature and genetic backgrounds39. In addition to infarct staining, we tested cardiac troponin I (cTnI)
as a marker of myocardial infarction in this model. In fact, plasma levels of cTnI correlated with infarct sizes (R2=0.8). Finally, we could show in several studies that this technique yields highly reproducible infarct sizes during murine IP and myocardial infarction6, 8, 30, 40, 41. Therefore, this technique may be helpful for researchers who pursue molecular mechanisms involved in cardioprotection by IP using a genetic approach in mice with targeted gene deletion. Further studies on cardiac IP using transgenic mice may consider this technique.

A murine model for myocardial ischemia and ischemic preconditioning is an important tool study cardioprotective mechanisms in vivo. Here, we report an easy applicable in situ model for cardiac IP using a hanging-weight system for coronary artery occlusion.

El uso de un sistema de peso que cuelga de la oclusión coronaria en ratones

Murine studies of acute injury are an area of intense investigation, as knockout mice for different genes are becoming increasingly available 1-38. ...

Modified Technique for Coronary Artery Ligation in Mice

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI we need better knowledge about pathophysiology of myocardial ischemia. This knowledge may be valuable to define new therapeutic targets for innovative cardiovascular therapies4. Experimental MI model in mice is an increasingly popular small-animal model in preclinical research in which MI is induced by means of permanent or temporary ligation of left coronary artery (LCA)5. In this video, we describe the step-by-step method of how to induce experimental MI in mice.
The animal is first anesthetized with 2% isoflurane. The unconscious mouse is then intubated and connected to a ventilator for artificial ventilation. The left chest is shaved and 1.5 cm incision along mid-axillary line is made in the skin. The left pectoralis major muscle is bluntly dissociated until the ribs are exposed. The muscle layers are pulled aside and fixed with an eyelid-retractor. After these preparations, left thoracotomy is performed between the third and fourth ribs in order to visualize the anterior surface of the heart and left lung. The proximal segment of LCA artery is then ligated with a 7-0 ethilon suture which typically induces an infarct size ~40% of left ventricle. At the end, the chest is closed and the animals receive postoperative analgesia (Temgesic, 0.3 mg/50 ml, ip). The animals are kept in a warm cage until spontaneous recovery.

The surgical procedure used to induce experimental myocardial infarction in mice begins with left thoracotomy between the third and the fourth ribs in order to visualize the anterior surface of the heart and left lung. The left coronary artery is ligated, the chest is closed and the mouse is allowed to recover spontaneously.

Técnica modificada para la ligadura de la arteria coronaria en ratones

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI ...

Evaluation of Respiratory Muscle Activation Using Respiratory Motor Control Assessment (RMCA) in Individuals with Chronic Spinal Cord Injury

During breathing, activation of respiratory muscles is coordinated by integrated input from the brain, brainstem, and spinal cord. When this coordination is disrupted by spinal cord injury (SCI), control of respiratory muscles innervated below the injury level is compromised1,2 leading to respiratory muscle dysfunction and pulmonary complications. These conditions are among the leading causes of death in patients with SCI3. Standard pulmonary function tests that assess respiratory motor function include spirometrical and maximum airway pressure outcomes: Forced Vital Capacity (FVC), Forced Expiratory Volume in one second (FEV1), Maximal Inspiratory Pressure (PImax) and Maximal Expiratory Pressure (PEmax)4,5. These values provide indirect measurements of respiratory muscle performance6. In clinical practice and research, a surface electromyography (sEMG) recorded from respiratory muscles can be used to assess respiratory motor function and help to diagnose neuromuscular pathology. However, variability in the sEMG amplitude inhibits efforts to develop objective and direct measures of respiratory motor function6. Based on a multi-muscle sEMG approach to characterize motor control of limb muscles7, known as the voluntary response index (VRI)8, we developed an analytical tool to characterize respiratory motor control directly from sEMG data recorded from multiple respiratory muscles during the voluntary respiratory tasks. We have termed this the Respiratory Motor Control Assessment (RMCA)9. This vector analysis method quantifies the amount and distribution of activity across muscles and presents it in the form of an index that relates the degree to which sEMG output within a test-subject resembles that from a group of healthy (non-injured) controls. The resulting index value has been shown to have high face validity, sensitivity and specificity9-11. We showed previously9 that the RMCA outcomes significantly correlate with levels of SCI and pulmonary function measures. We are presenting here the method to quantitatively compare post-spinal cord injury respiratory multi-muscle activation patterns to those of healthy individuals.

Evaluation of Respiratory Muscle Activation Using Respiratory Motor Control Assessment RMCA in Individuals with Chronic Spinal Cord Injury

The purpose of this publication is to present our original work on a multi-muscle surface electromyographic approach to quantitatively characterize respiratory muscle activation patterns in individuals with chronic spinal cord injury using vector-based analysis.

Evaluación de activación muscular respiratoria Utilizar evaluaciones de control de motores respiratoria (RMCA) en personas con lesión de la médula espinal crónica

During breathing, activation of respiratory muscles is coordinated by integrated input from the brain, brainstem, and spinal cord. When this coordination ...

A Novel Application of Musculoskeletal Ultrasound Imaging

Ultrasound is an attractive modality for imaging muscle and tendon motion during dynamic tasks and can provide a complementary methodological approach for biomechanical studies in a clinical or laboratory setting. Towards this goal, methods for quantification of muscle kinematics from ultrasound imagery are being developed based on image processing. The temporal resolution of these methods is typically not sufficient for highly dynamic tasks, such as drop-landing. We propose a new approach that utilizes a Doppler method for quantifying muscle kinematics. We have developed a novel vector tissue Doppler imaging (vTDI) technique that can be used to measure musculoskeletal contraction velocity, strain and strain rate with sub-millisecond temporal resolution during dynamic activities using ultrasound. The goal of this preliminary study was to investigate the repeatability and potential applicability of the vTDI technique in measuring musculoskeletal velocities during a drop-landing task, in healthy subjects. The vTDI measurements can be performed concurrently with other biomechanical techniques, such as 3D motion capture for joint kinematics and kinetics, electromyography for timing of muscle activation and force plates for ground reaction force. Integration of these complementary techniques could lead to a better understanding of dynamic muscle function and dysfunction underlying the pathogenesis and pathophysiology of musculoskeletal disorders.

We describe a new ultrasound-based vector tissue Doppler imaging technique to measure muscle contraction velocity, strain and strain rate with sub-millisecond temporal resolution during dynamic activities. This approach provides complementary measurements of dynamic muscle function and could lead to a better understanding of mechanisms underlying musculoskeletal disorders.

Una aplicación Novel of Musculoskeletal Ultrasound Imaging

Ultrasound is an attractive modality for imaging muscle and tendon  motion during dynamic tasks and can provide a complementary methodological  approach ...

Ultrasound Based Assessment of Coronary Artery Flow and Coronary Flow Reserve Using the Pressure Overload Model in Mice

Transthoracic Doppler echocardiography (TTDE) is a clinically useful, noninvasive tool for studying coronary artery flow velocity and coronary flow reserve (CFR) in humans. Reduced CFR is accompanied by marked intramyocardial and pericoronary fibrosis and is used as an indication of the severity of dysfunction. This study explores, step-by-step, the real-time changes measured in the coronary flow velocity, CFR and systolic to diastolic peak velocity (S/D) ratio in the setting of an aortic banding model in mice. By using a Doppler transthoracic imaging technique that yields reproducible and reliable data, the method assesses changes in flow in the septal coronary artery (SCA), for a period of over two weeks in mice, that previously either underwent aortic banding or thoracotomy. 
During imaging, hyperemia in all mice was induced by isoflurane, an anesthetic that increased coronary flow velocity when compared with resting flow. All images were acquired by a single imager. Two ratios, (1) CFR, the ratio between hyperemic and baseline flow velocities, and (2) systolic (S) to diastolic (D) flow were determined, using a proprietary software and by two independent observers. Importantly, the observed changes in coronary flow preceded LV dysfunction as evidenced by normal LV mass and fractional shortening (FS). 
The method was benchmarked against the current gold standard of coronary assessment, histopathology. The latter technique showed clear pathologic changes in the coronary artery in the form of peri-coronary fibrosis that correlated to the flow changes as assessed by echocardiography. 
The study underscores the value of using a non-invasive technique to monitor coronary circulation in mouse hearts. The method minimizes redundant use of research animals and demonstrates that advanced ultrasound-based indices, such as CFR and S/D ratios, can serve as viable diagnostic tools in a variety of investigational protocols including drug studies and the study of genetically modified strains.

Coronary flow reserve (CFR) is useful for assessment of myocardial oxygen demand and evaluation of cardiovascular risk. This study establishes a step-by-step transthoracic Doppler echocardiographic (TTDE) method for longitudinal monitoring of the changes in CFR, as measured from coronary artery in mice, under the experimental pressure overload of aortic banding.

Evaluación Ultrasonido base de la arteria coronaria de flujo y la reserva coronaria Utilizando la sobrecarga Modelo Presión en ratones

Transthoracic Doppler echocardiography (TTDE) is a clinically useful, noninvasive tool for studying coronary artery flow velocity and coronary flow ...

'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake

Different methods can be used in research to assess dietary intake, many of which are still paper-based. Written estimated food diaries are often utilized in clinical trials, despite being a burden for both study participants and researchers. This method requires participant literacy, it is time consuming, labor intensive, and can easily lead to under-reporting. With advancements in technology, there is a growing interest in electronic diaries that automate the dietary assessment process. These are focused on improving accuracy, reducing both time and cost and providing users with a visual and more enjoyable experience. The methodology presented here aimed to validate the &#39;Boden Food Plate&#39;, a novel web-based platform for self-recording of food and drink items, compared to a traditional estimated food diary. The application was also rated on a satisfaction scale by study participants using a paper-based questionnaire. Sixty-seven participants completed the dietary measures on both the three-day electronic and paper food diaries. For the analysis, only dietary data completed at both study time points (baseline and week six) was utilized. Despite small mean differences between dietary data collection methods, Bland Altman analysis showed fairly wide 95% limits of agreement between the electronic platform and the written estimated food diary and there were few cases which did not fall within the 95% confidence intervals. Overall, participants found the electronic food diary to be more fun than the paper method and as easy to use as hard copy diaries. The new platform has potential as a self-recording tool for the collection of dietary data, particularly when utilized in clinical trial settings. However, further validation studies are needed to improve the validity of this novel electronic dietary data collection tool.

The &#39;Boden Food Plate&#39; is an electronic food diary designed to be an interactive and fun method to collect dietary intake using visual depictions. The purpose of this study was to validate the web-based application against a traditional three-day estimated food diary method.

'Placa del alimento de Boden': nuevo método interactivo basado en Web para la evaluación de ingesta dietética

Different methods can be used in research to assess dietary intake, many of which are still paper-based. Written estimated food diaries are often utilized ...

Coronary Progenitor Cells and Soluble Biomarkers in Cardiovascular Prognosis after Coronary Angioplasty

Major adverse cardiovascular events (MACEs) negatively impact the cardiovascular prognosis of patients undergoing coronary angioplasty due to coronary ischemic injury. The extent of coronary damage and the mechanisms of vascular repair are factors influencing the future development of MACEs. Intrinsic vascular features like the plaque characteristics and coronary artery complexity have demonstrated prognostic information for MACEs. However, the use of intracoronary circulating biomarkers has been postulated as a convenient method for the early identification and prognosis of MACEs, as they more closely reflect dynamic mechanisms involving coronary damage and repair. Determination of coronary circulating biomarkers during angioplasty, such as the number of subpopulations of mononuclear progenitor cells (MPCs) as well as the concentration of soluble molecules reflecting inflammation, cell adhesion, and repair, allows for assessment of future developments and the prognosis of MACEs 6 months post coronary angioplasty. This method is highlighted by its translational nature and better performance than peripheral blood circulating biomarkers regarding prediction of MACEs and its effect on the cardiovascular prognosis, which may be applied for risk stratification of patients with coronary artery disease undergoing angioplasty.

Development of major adverse cardiovascular events, which impact cardiovascular prognosis after coronary angioplasty, are influenced by the extent of coronary damage and vascular repair. The use of novel coronary cellular and soluble biomarkers, reactive to vascular damage and repair, are useful to predict the development of MACEs and prognosis.

Células progenitoras coronarias y biomarcadores solubles en pronóstico cardiovascular después de la angioplastia coronaria

Major adverse cardiovascular events (MACEs) negatively impact the cardiovascular prognosis of patients undergoing coronary angioplasty due to coronary ...

In Vitro Model of Coronary Angiogenesis

Here, we describe an in vitro culture assay to study coronary angiogenesis. Coronary vessels feed the heart muscle and are of clinical importance. Defects in these vessels represent severe health risks such as in atherosclerosis, which can lead to myocardial infarctions and heart failures in patients. Consequently, coronary artery disease is one of the leading causes of death worldwide. Despite its clinical importance, relatively little progress has been made on how to regenerate damaged coronary arteries. Nevertheless, recent progress has been made in understanding the cellular origin and differentiation pathways of coronary vessel development. The advent of tools and technologies that allow researchers to fluorescently label progenitor cells, follow their fate, and visualize progenies in vivo have been instrumental in understanding coronary vessel development. In vivo studies are valuable, but have limitations in terms of speed, accessibility, and flexibility in experimental design. Alternatively, accurate in vitro models of coronary angiogenesis can circumvent these limitations and allow researchers to interrogate important biological questions with speed and flexibility. The lack of appropriate in vitro model systems may have hindered the progress in understanding the cellular and molecular mechanisms of coronary vessel growth. Here, we describe an in vitro culture system to grow coronary vessels from the sinus venosus (SV) and endocardium (Endo), the two progenitor tissues from which many of the coronary vessels arise. We also confirmed that the cultures accurately recapitulate some of the known in vivo mechanisms. For instance, we show that the angiogenic sprouts in culture from SV downregulate COUP-TFII expression similar to what is observed in vivo. In addition, we show that VEGF-A, a well-known angiogenic factor in vivo, robustly stimulates angiogenesis from both the SV and Endo cultures. Collectively, we have devised an accurate in vitro culture model to study coronary angiogenesis.

In vitro models of coronary angiogenesis can be utilized for the discovery of the cellular and molecular mechanisms of coronary angiogenesis. In vitro explant cultures of sinus venosus and endocardium tissues show robust growth in response to VEGF-A and display a similar pattern of COUP-TFII expression as in vivo.

Modelo In Vitro de Angiogénesis Coronaria

Here, we describe an in vitro culture assay to study coronary angiogenesis. Coronary vessels feed the heart muscle and are of clinical importance. Defects ...

Testing Acetylcholine Followed by Adenosine for Invasive Diagnosis of Coronary Vasomotor Disorders

More than 50% of patients with signs and symptoms of myocardial ischemia undergoing coronary angiography have unobstructed coronary arteries. Coronary vasomotor disorders (impaired vasodilatation and/or enhanced vasoconstriction/spasm) represent important functional causes for such a clinical presentation. Although impaired vasodilatation may be assessed with non-invasive techniques such as positron emission tomography or cardiac magnetic resonance imaging, there is currently no reliable non-invasive technique for the diagnosis of coronary spasm available. Thus, invasive diagnostic procedures (IDP) have been developed for the diagnosis of coronary vasomotor disorders including spasm testing as well as assessment of coronary vasodilatation. The identification of the underlying type of disorder (so called endotype) allows the initiation of targeted pharmacological treatments. Despite the fact that such an approach is recommended by the current European Society of Cardiology guidelines for the management of chronic coronary syndromes based on the CorMicA study, comparability of results as well as multicenter trials are currently hampered by major differences in institutional protocols for coronary functional testing. This article describes a comprehensive IDP protocol including intracoronary acetylcholine provocation testing for diagnosis of epicardial/microvascular spasm, followed by Doppler wire-based assessment of coronary flow reserve (CFR) and hyperemic microvascular resistance (HMR) in search of coronary vasodilatory impairment.

Coronary vasomotion disorders represent frequent functional causes of angina in patients with unobstructed coronaries. The underlying mechanism of angina (endotype) in these patients can be determined by a comprehensive invasive diagnostic procedure based on acetylcholine provocation testing followed by Doppler-derived assessment of the coronary flow reserve and microvascular resistance.

Prueba de acetilcolina seguida de adenosina para el diagnóstico invasivo de trastornos vasomotores coronarios

More than 50% of patients with signs and symptoms of myocardial ischemia undergoing coronary angiography have unobstructed coronary arteries. Coronary ...