J Korean Soc Echocardiogr.  1994 Jul;2(1):1-12. 10.4250/jkse.1994.2.1.1.

Intravenous Ergonovine Test with Two Dimensional Echocardiography for Diagmosis of Coronary Artery Spasm

• Song JK
• Park SW
• Kim JJ
• Cheong SS
• Kang DH
• Park SJ
• Lee SJ

• KMID: 2410454
• DOI: http://doi.org/10.4250/jkse.1994.2.1.1

Abstract

BACKGROUND
Noninvasive diagnostic test to document coronary artery spasm would be useful in the management of patients with variant angina, especially in the screening, evaluation of the medication effects and determination of the clinical activity of the disease. The purpose of this study was to evaluate the clinical feasibility of bedside ergonovine test with digital echocardiography and side-by-side continuous cine-loop display method(ergonovine echocardiography) as a noninvasive diagnostic method for coronary artery spasm.
METHODS
Bedside ergonovine test was performed in 66 patients who showed coronary vasospasm during coronary angiography including provocation test (variant angina group) and in 39 patients with normal angiogram and no evidence of coronary artery spasm(nonanginal pain group). A bolus of ergonovine maleate (.025 or .05mg) was injected at 5 min intervals up to total cumulative dosage of .35mg, and 12-leads ECG and 2 dimensional echocardiography were recorded every 3min after each injection. Left ventricular wall motion was analyzed with a commercially available "˜QUAD' system. The positive criteria of bedside ergonovine test included reversible ST segment elevation of depression in ECG(ECG criteria) and reversible regional wall motion abnormalities in echocardiography(Echo criteria).
RESULTS
The overall sensitivity and specificity of ECG criteria were 53%(35/66,95% confidence interval[CI], 41 to 65%) and 100% respectively. By Echo criteria the sensitivity increased up to 89%(59/66,95% CI, 81 to 97%) with the specificity of 95%(37/39). Concomitant fixed coronary lesion increased the sensitivity of the test compared with pure coronary artery spasm with ECG criteria (95% vs 35%, p < 0.05). According to Echo criteria mean dose of ergonovine with positive result was 150±75µg and the amount of ergonovine for positive result was significantly larger in patients with low disease activity (chest pain < 5 times a week) than those with high disease activity(207±81 vs 106±73µg, p < 0.01) : concomitant mild fixed coronary disease decreased the ergonovine dosage compared with pure coronary vasospasm (93±65 vs 168±102µg, p < 0.05). There was no procedure related serious arrhythmias nor fatality.
CONCLUSIONS
Ergonovine Echocardiography is a highly sensitive and specific test for coronary vasospasm and is safe in selected patients in whom the noninvasive stress test is negative and severs fixed coronary artery disease has veen excluded. Presence of concomitant fixed coronary disease and the degree of clinical activity of coronary vasospasm may influence the results of this test.

Keyword

Coronary artery spasm; Ergonovine echocardiography; Noninavasive diagnosis

MeSH Terms

Arrhythmias, Cardiac
Coronary Angiography
Coronary Artery Disease
Coronary Disease
Coronary Vasospasm
Coronary Vessels*
Depression
Diagnostic Tests, Routine
Echocardiography*
Electrocardiography
Ergonovine*
Exercise Test
Humans
Mass Screening
Methods
Sensitivity and Specificity
Spasm*
Ergonovine

Figure

• 

  Fig. 1. An example of ergonovine echocardiography in a patient with documented coronary vasospasm in the right coronary artery. Left ventricular(LV) wall motion at end systole was displayed in ‘QUAD’ screen. No definite regional wall motion abnormality at basal status(A) and after 0.05mg ergonovine injection(B). With 0.1 mg ergonovine injection severe hypokinesia and akinesia with loss of systolic wall thickening developed in mid inferior segment, which resulted in so-called ‘cavitary sign’(C). These wall motion abnormalities reversed promptly with nitroglycerin admmistration(D).

• 

  Fig. 2. Changes of vital signs with ergonovine injection.

Reference

References

1). Maseri A, Severi S, De Nes M, L'Abbate A, Chierchia S, Marzilli M, Ballestra AM, Parodi O, Biagini A, Distante A. Variant angina: one aspect of a continuous spectrum of vasospastic myocardial ischemia. Am J Cardiol. 1978; 42:1019–1035.

2). Heupler FA. Provocative testing for coronary arterial spasm: Risk, method and rationale. Am J Cardiol. 1980; 46:335–337.

3). Waters DD, Theroux P, Szlachcic J, Dauwe F, Crittin J, Bonnan R, Mizgala HF. Ergonovine testing in a coronary care unit. Am J Cardiol. 1980; 40:922–930.

4). Song JK, Park SW, Doo YC, Kim JJ, Park SJ, Lee JK. Clinical feasibility of bedside intravenous ergonovine test on the diagnosis of variant angina. Korean Circulation J. 1992; 22:71–81.

5). Mizushige K. Evaluation of regional and total cardiac function during attack of variant angina. Nippon-Naika-Gakkai-Zasshi. 1983; 72:995–1005.

6). Distante A, Rovai D, Picano E, Moscarelli E, Morales MA, Palombo C, L'Abbate A. Transient changes in left ventricular mechanics during attacks of Prinzmetal angina: A two-dimensional echocardiographic study. Am Heart J. 1984; 108:440–446.

7). Fujii H, Yasue H, Okumura K, Matsuyama K, Morikami Y, Miyagi H, Ogawa H. Hyperventilation-induced simultaneous multivessel coronary spasm in patients with variant angina: An echocardiographic and arteriographic study. J Am Coll Cardiol. 1988; 12:1184–92.

8). Ross J Jr. Mechanisms of regional ischemia and antianginal drug action during exercise. Prog Cardiovasc Dis. 1989; 31:455–466.

9). Gallagher KP, Matsuzaki M, Osakada G, Kemper WS, Ross J Jr. Effect of exercise on the relationship between myocardial blood flow and systolic wall thickening in dogs with acute coronary stenosis. Circ Res. 1983; 52:716–729.

10). Nesto RW, Kowalchuck GJ. The ischemic cascade: Temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol. 1987; 57:23–27.

11). Feigenbaum H. Exercise echocardiography. J Am Soc Echocardiogr. 1988; 1:161–166.

12). Picano E. Stress echocardiography: From pathophysiological toy to diagnostic tool. Circulation. 1992; 85:1604–1612.

13). Okumura K, Yasue H, Matsuyama K, Goto K, Miyagi H, Ogawa H. Sensitivity and specificity of intracoronary injection of acetylcholine for the induction of coronary artery spasm. J Am Coll Cardiol. 1988; 12:883–888.

14). Park SW, Park SJ, Kim JJ, Song JK, Seong IW, Lee JK. A comparative study of acetylcholine and ergonovine provocative test in patients with chest pain syndrome with normal or near normal coronary arteriograms. Korean Circulation J. 1991; 21:842–848.

15). Waters DD, Szlachcic J, Theroux P, Dauwe F, Mizgala H. Ergonovine testing to detect spontaneous remissions of variant angina during long term treatment with calcium antagonist drugs. Am J Cardiol. 1981; 47:179–183.

16). Winnifold MD, Johnson SM, Mauritson DR, Hills LD. Ergonovine provocation to assess efficacy of long term therapy with calcium antagonists in Prinzmetal's variant angina. Am J Cardiol. 1983; 51:684–688.

17). Whittle JL, Feldman RL, Pepine CJ, Curry RC, Conti CR. Variabilty of electrocardiographic responses to repeated ergonovine provocation in variant angina patients with coronary artery spasm. Am Heart J. 1982; 103:161–167.

18). Feldman RL, Hill JA, Whittle JL, Conti CR, Pepine CJ. Eletrocardiographic changes with coronary artery spasm. Am Heart J. 1983; 106:1288–1297.

19). Dart AM, Alban-Davies H, Lowndes RH. Ergometrine-induced “angina” – a diagnostic pitfall. Br Heart J. 1980; 43:104.

20). Egeblad H, Vilhelmsen R, Mortensen SA. Ischemic and postischemic ventricular wall motion abnormalities in Prinzmetal's angina provoked by hyperventilation. Am Heart J. 1982; 104:1105–1107.

21). Distante A, Rovai D, Picano E, Moscarelli E, Palombo C, Morales MA, Michelassi C, L'Abbate A. Transient changes in left ventricular mechanics during attacks of Prinzmetal's angina: An M-mode echocardiographic study. Am Heart J. 1984; 107:465–474.

22). Distante A, Picano E, Moscarelli E, Palombo C, Benassi A, L'Abbate A. Echocardiographic versus hemodynamic monitoring during attacks of variant angina pectoris. Am J Cardiol. 1985; 55:1319–1322.

23). Rovai D, Distante A, Moscarelli E, Morales MA, Picano E, Palombo C, L'Abbate A. Transient myocardial ischemia with minimal electrocariographic changes: An echocardiographic study in patients with Prinzmetal's angina. Am Heart J. 1985; 109:78–83.