Published: February 3rd, 2021
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.
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.
In recent years interventional cardiology has made substantial progress in various areas. This not only comprises interventional treatment of the heart valves using transcatheter aortic valve replacement and edge-to-edge repair of the mitral and tricuspid valve, but also coronary interventions1,2,3,4,5,6. Among the latter are advances in techniques for treatment of chronic total occlusions as well as calcified lesions using rotablation and shock wave therapy. In addition t....
Intracoronary ACh testing has been approved by the local ethics committee and the protocol follows the guidelines of our institution for human research. A previous JoVE article covered a protocol showing preparation of the ACh solutions as well as preparation of the syringes for intracoronary injection of ACh15.
1. Preparation of the ACh solutions and preparation of the syringes for intracoronary injection of ACh
According to the diagnostic criteria suggested by COVADIS9, vasospastic angina can be diagnosed if the following criteria apply during ACh provocation testing: transient ECG changes indicating ischemia, reproduction of the patient´s usual anginal symptoms and > 90% vasoconstriction of an epicardial vessel as confirmed during coronary angiography (Figure 2).
Management of patients with angina and unobstructed coronary arteries is often demanding and sometimes frustrating. An important step during the work-up of these patients is that the underlying pathophysiological mechanism(s) for the patient's symptoms are adequately investigated. This is challenging as often not only one mechanism is responsible and various aetiologies including cardiac and non-cardiac as well as coronary and non-coronary need to be taken into account.
|Cannula 0,95 x 50 mm (arterial punction)
|Cannula 23 G 0,6 x 25 mm (local anesthesia)
|Coronary angiography suite (AXIOM Artis MP eco)
|Contrast agent Imeron 350 with a 10 mL syringe for contrast injection
|Diagnostic catheter (various manufacturers)
|Glidesheath Slender 6 Fr
|Heparin 5,000 IU (25,000 IU / 5 mL)
|Mepivacaine 10 mg/mL
|Sodium chloride solution 0.9 % (1 x 100 mL)
|Syringe 2 mL (1x) (local anesthesia)
|Syringe 10 mL (1x) (Heparin)
|Acetylcholine chloride (vial of 20 mg acetylcholine chloride powder and 1 ampoule of 2 mL diluent)
|Bausch & Lomb
|Cannula 20 G 70 mm (2x)
|Glyceryle Trinitrate 1 mg/mL (5 mL)
|Sodium chloride solution 0.9 % (3 x 100 mL)
|Syringe 2 mL (1x)
|Syringe 5 mL (5x)
|Syringe 10 mL (1x)
|Syringe 50 mL (3x)
|Adenosine 6 mg/2 mL
|ComboMap Pressure/Flow System
|Model No. 6800 (Powers Up)
|Pressure/Flow Guide Wire
|Sodium chloride solution 0.9 % (1 x 100 mL)
|Syringe 10 mL (3x)
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