PCI complications: coronary vasospasm: Difference between revisions

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==Overview==
==Overview==
[[Coronary vasospasm]] can be induced by [[percutaneous coronary interventions]] (PCI) secondary to [[endothelial]] denudation and [[nitric oxide]] loss.  The main goal of the treatment of angioplasy- induced coronary vasospasm is to reverse angioplasty-induced vasospasm.  The initial treatment is [[intracoronary pharmacotherapy|intracoronary]] [[vasodilatation]] with [[calcium channel blockers]] and/or [[nitrates]], which should be given slowly when using [[PCI equipment: guiding catheter selection|guiding catheters]].  Therapies for [[vasospasm]] will usually take effect within seconds to one minute.
[[Coronary vasospasm]] can be induced by [[percutaneous coronary intervention]] (PCI) secondary to [[endothelial]] denudation and [[nitric oxide]] loss.  The main goal of the treatment of angioplasy- induced coronary vasospasm is to reverse angioplasty-induced vasospasm.  The initial treatment is [[intracoronary pharmacotherapy|intracoronary]] [[vasodilatation]] with [[calcium channel blockers]] and/or [[nitrates]], which should be given slowly when using [[PCI equipment: guiding catheter selection|guiding catheters]].  Therapies for [[vasospasm]] will usually take effect within seconds to one minute.


==Classification==
==Classification==

Revision as of 20:42, 2 May 2014

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Coronary vasospasm can be induced by percutaneous coronary intervention (PCI) secondary to endothelial denudation and nitric oxide loss. The main goal of the treatment of angioplasy- induced coronary vasospasm is to reverse angioplasty-induced vasospasm. The initial treatment is intracoronary vasodilatation with calcium channel blockers and/or nitrates, which should be given slowly when using guiding catheters. Therapies for vasospasm will usually take effect within seconds to one minute.

Classification

Focal coronary spasm

Focal coronary spasm is limited to a localized segment of the coronary artery.

Multifocal coronary spasm

Multifocal coronary spasm involves several localized segments of the same coronary artery.

Multivessel coronary spasm

Multivessel coronary spasm involves several coronary arteries.[1][2]

Pathophysiology

Coronary vasospasm can be induced by angioplasty (PCI-induced), which occurs secondary to endothelial denudation and nitric oxide loss. Some cases are catheter-induced which is caused by a contact of a catheter without balloon deployment. Catheter-induced coronary vasospasm is usually short-lived. Catheter-induced coronary vasospasm is most prone to occur at the ostium of the right coronary artery (RCA). The left main is less susceptible to ostial spasm.

Differential Diagnosis

Epidemiology and Demographics

  • Occasionally, coronary vasospasm can be induced by angioplasty (PCI-induced).
  • Rotoblator cases are more prone to coronary vasospasm. The reported incidence of rotoblater cases with coronary vasospasm ranges anywhere from 4 to 36%.

Risk factors

Smoking is a risk factor for coronary vasospasm.

Diagnosis

  • Physicians should suspect vasospasm if ST segment elevation is detected in patients experiencing angina, and if the ECG completely returns to baseline upon resolution of symptoms.
  • The definitive diagnosis of coronary vasospasm is made angiographically by demonstration of reduction of luminal diameter in a discrete segment of the vessel, which is proven to be reversible.
  • Reversibility may be demonstrated by previous or subsequent enlargement of luminal diameter, often after the administration of intracoronary vasodilators.

Treatment

  • Therapeutic treatment of PCI-induced vasospasm should be performed in this order (step-wise fashion):

How To Know if Treatment of PCI-Induced Vasospam is Working

Therapies for vasospasm will usually take effect within seconds to one minute. Anticipated outcomes include:

  • Resolution of acute or chronic coronary vasospasm
  • Resolution of ECG changes (ST depression or elevation)
  • Resolution of symptomatic angina and other symptoms, if present
  • Repeat angiography

Other Concerns

There are several additional factors that doctors should mindful of when considering coronary vasospasm treatments, complications, and outcomes.

  • Coronary vasospasm can lead to life-threatening arrhythmias, depending on the vessel that is involved. Specifically, right coronary artery spasm can lead to sinus arrest or complete heart block, while left anterior descending artery spasm can lead to ventricular tachycardia or fibrillation. Multivessel spasm can also lead to ventricular arrhythmias.
  • The right coronary artery ostium is prone to catheter-induced spasm, giving the appearance of an ostial lesion on angiography. Pre-treatment with 200 mcg of IC nitroglycerin should be administered prior to intervention of this area.
  • Patients who have coronary artery disease in addition to coronary vasospasm have an overall worse prognosis.

References

  1. Ahooja V, Thatai D (2007). "Multivessel coronary vasospasm mimicking triple-vessel obstructive coronary artery disease". J Invasive Cardiol. 19 (7): E178–81. PMID 17620681. Unknown parameter |month= ignored (help)
  2. Miwa K, Ishii K, Makita T, Okuda N (2004). "Diagnosis of multivessel coronary vasospasm by detecting postischemic regional left ventricular delayed relaxation on echocardiography using color kinesis". Circ. J. 68 (5): 483–7. PMID 15118293. Unknown parameter |month= ignored (help)

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