Key result
Positive acetylcholine test responses are linked to higher MACE risk regardless of specific spasm phenotype.
Why the study?
Epicardial spasm phenotypes may relate to prognosis in coronary spastic angina, but the relationship between angiographic coronary vasomotor responses to intracoronary acetylcholine and prognosis in ANOCAD was unclear.
Do provoked epicardial spasm phenotypes via intracoronary acetylcholine testing predict prognosis in patients with angina and nonobstructive coronary arteries?
Observational (n=680)
No
Do provoked epicardial spasm phenotypes via intracoronary acetylcholine testing predict prognosis in patients with angina and nonobstructive coronary arteries?
Patients with ANOCAD and positive or unclassified acetylcholine provocation tests have worse clinical outcomes than those with completely negative tests, regardless of the specific epicardial spasm phenotype.
Acetylcholine testing may risk-stratify ANOCA patients; leaves open whether spasm phenotypes should guide therapy.
Background: Epicardial spasm (ES) phenotypes may be related to the prognosis in patients with coronary spastic angina. Objectives: The purpose of this study was to elucidate the relationship between angiographic coronary vasomotor responses to intracoronary acetylcholine (ACh) injection and prognosis in patients with angina and nonobstructive coronary artery disease (ANOCAD). Methods: This was a retrospective, observational, single-center study of 680 patients with ANOCAD. ACh spasm provocation tests on both coronary arteries were performed without administering nitroglycerine to relieve provoked spasm in a first-attempt artery. ACh was injected in incremental doses of 20/50/100/200 μg into the left coronary artery and 20/50/80 μg into the right coronary artery. Positive ES was defined as ≥90% stenosis and usual chest pain and ischemic ECG changes. Results: Provoked positive ES was observed in 310 patients (46%), including 85 patients (13%) with focal spasm, 150 patients (22%) with diffuse spasm, and 75 patients (11%) with combined spasm (diffuse spasm and focal spasm), whereas the remaining 370 patients (54%) had no provoked spasm. An unclassified ACh test was observed in 186 patients (27%), while 184 patients (27%) had a complete negative ACh test. The clinical outcomes in patients with complete negative ES were satisfactory compared with those with positive ES and unclassified ACh test results. The prognosis in patients with an unclassified ACh test was not different from those with a positive ES. Furthermore, prognosis in patients with ES phenotypes was not different among the three groups. Conclusions: There was no correlation between provoked ES phenotypes via intracoronary ACh testing and prognosis in patients with ANOCAD; however, clinical outcomes in patients with positive ES and unclassified ACh tests were worse compared to those with complete negative ACh tests. We should focus on the treatments in patients with unclassified ACh tests as well as those with ESs.
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Sueda et al. (2022) conducted an observational in Angina and nonobstructive coronary artery disease (ANOCAD) (n=680). Positive epicardial spasm (ES) or unclassified acetylcholine test response vs. Complete negative acetylcholine test was evaluated on Major adverse cardiac events (MACEs). Positive epicardial spasm and unclassified acetylcholine test responses were associated with worse clinical outcomes compared to completely negative tests, although specific spasm phenotypes (diffuse, focal, or combined) had no differential impact on prognosis.
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