Name: intracoronary acetylcholine provocation testing for assessment of coronary vasomotor disorders
Uploaded: 2016-08-18T14:00:00
Description: Watch this Scientific Journal Video about Intracoronary Acetylcholine Provocation Testing for Assessment of Coronary Vasomotor Disorders at JoVE.com

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

MERK: intra acetylkolin testing har blitt godkjent av lokale etikkutvalg og protokollen følger retningslinjene i vår institusjon for menneske forskning. 1. Utarbeidelse av acetylkolin Solutions (Se Materials Table) <ol><li> Bland 20 mg acetylkolin med 2 ml væske som følger med pakken. </li><li> Tilsett 2 ml ACH oppløsning til 98 ml NaCl 0,9%. Dette tilsvarer en dose på 0,2 mg / ml og kalles stamoppløsning 1. Tilsett 9 ml av stamoppløsning 1-91 ml NaCl 0,9%, dette tilsvarer en dose ...

<ol>
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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. 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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>

Det er mulig å gjennomføre den acetylkolin-testen i daglige kliniske rutine i kateterisering laboratoriet. Bortsett fra utarbeidelse av ACH løsninger er det flere tekniske problemer som må løses før du starter testen inkludert gjennomlysbart EKG fører til kontinuerlig 12-avlednings EKG registrering. Dette er viktig å være i stand til å detektere transiente iskemiske EKG-forandringer under testen. Videre er det viktig å vite at ACH-løsninger kan bare brukes i 2 timer. Etter at de bør nypreparerte. <p cla...

Angina pectoris er kjennetegnet av koronarsykdom og konseptet med en epikardial stenose forårsaker myokardiskemi og anstrengelsesutløst angina har vært etablert i mange år. Men mange pasienter med angina pectoris ikke den typiske triaden av retrosternale smerter, utbruddet under trening og lindring av nitroglyserin eller hvile. Ofte pasienter rapporterer angina pectoris i ro eller en kombinasjon av anstrengelse og hvile angina samt kortpustethet ved anstrengelse som mulig angina tilsvarende. I 1959 Prinzmetals var den første til å introdusere begrepet forbigående spasmer i koronararteriene forårsaker angina i ro forbundet med ST-segment elevasjon på elektrokardiogram (EKG), men med bevart arbeidskapasiteten en. Denne hypotesen ble bekreftet senere ved hjelp av koronar angiografi og det viste seg at coronary krampe kan være til stede hos pasienter med epikardiale stenoser eller normale koronararteriene 2. I 1980ies intra acetylkolin provokasjon testing (ACH-test) for påvisning av koronar spasme ble etablert i Japan og senere interessert i klinisk forskning for koronar spasme økt tre. Men etter innføringen av perkutan koronar intervensjon i 1977 og den første stent i 1986 interessen for koronar vasomotoriske forstyrrelser falt betraktelig i hvert fall i Europa og USA. Det kan også være på grunn av den invasive natur av ACH-test (på grunn av den korte halveringstiden til ACH den bare kan administreres inn i koronararteriene for vurdering av koronar spasme). Likevel er det mange pasienter med tegn og symptomer på myokardiskemi ikke har noen relevant epikardiell stenose på koronar angiografi 4,5,6. Hos slike pasienter intra acetylkolin provokasjonstest er nyttig for å oppdage en klinisk relevant koronar vasomotorisk lidelse og innføre hensiktsmessig medisinsk behandling <sup&gt; 7. Acetylkolin er en nevrotransmitter i parasympatiske nervesystemet. Det fungerer via nikotinerge samt muscarinergic (mAChR) reseptorer. Sistnevnte er viktig for vaskulær homeostase og acetylkolin bindes på mAChR som en ikke-selektiv agonist. Aktivering av disse reseptorene på endotelial nivå fører til nitrogenoksid mediert vasodilatasjon, mens aktivering av mAChR på de vaskulære glatte muskelceller fører til vasokonstriksjon 8. Avhengig av integriteten til endotelet, og reaktiviteten av de glatte muskelceller nettoeffekten av intrakoronar administrering acetylkolin er vasodilatering eller vasokonstriksjon. Den fysiologiske responsen av koronararterier som reaksjon på acetylkolin i mennesker er ikke fullt ut forstått, men det har blitt rapportert at vasodilatasjon, så vel som vasokonstriksjon på opp til 25% av fartøyets diameter kan være fysiologisk, som vist i pasienter med normale kronarterier og ingen angina pectoris 9. Intra acetylkolin provokasjon testing har blitt anbefalt av European Society of Cardiology retningslinjer 10 samt de japanske Opplags Society retningslinjer 11 for vurdering av epikardiell og / eller mikrovaskulær spasmer hos pasienter med angina pectoris og uhindret koronararteriene. Intra acetylkolin provokasjonstesting er etablert i daglig klinisk rutine i kateteriseringslaboratoriet av vår institusjon i 2003. Siden 2006 en standardisert protokoll er fulgt 12. ACH-testing er vanligvis utføres på alle pasienter med tegn og symptomer på myokardiskemi ennå ingen relevant epikardiell stenose (&lt;50%) på koronar angiografi. ACH-testing utføres umiddelbart etter diagnostisk koronar angiografi i henhold til den protokoll som er beskrevet nedenfor. Ergonovin er et annet middel som brukes for spasmer provokasjon testing med en forskjellig virkningsmekanisme. Detaljertinformasjon om ergonovin testing kan finnes andre steder 12.

<table border="0" cellpadding="0" cellspacing="0" width="923">
	<tbody>
		<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>
</table>

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.

Tolkning av acetylkolin testen er basert på tre kriterier. Først blir pasienten bedt gjennom hele testen hvorvidt symptomene oppstår. Ofte pasienter rapporterer en reproduksjon av sine vanlige symptomer som brystsmerter, kortpustethet eller andre symptomer. Dette er et viktig punkt for den generelle tolkning av testen. For det andre er en 12-bly-EKG registrering kontinuerlig utføres gjennom hele testen med en spesiell vekt på iskemiske EKG skift som ST-segment depresjon, ST-segment ...

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.

Intra Acetylkolin provokasjonstest for vurdering av koronar vasomotorisk Disorders

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

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