Cardiology pp 431-450 | Cite as

Dynamic Coronary Stenosis: The Elusive Link between Coronary Atherosclerosis and Clinical Manifestations of Ischaemic Heart Disease

  • Attilio Maseri

Summary

Recent concepts on the roles of dynamic coronary stenosis in ischaemic heart disease are reviewed, with particular reference to episodes of transient myocardial ischaemia and their implications for patient management and therapy. The possible contribution of spasm and other obstructive mechanisms, such as platelet aggregation and thrombosis, to the various forms of angina pectoris, to myocardial infarction and sudden death are analysed in the light of clinical experience and clinical investigations. Based on these conceptual and clinical considerations, guidelines are suggested for future research and therapy. Long-term treatment with nitrates and calcium antagonists, which appear to be effective in preventing dynamic stenoses, resulted in low mortality and infarction rates over a period of two to four years, in a group of patients with ischaemic heart disease at high risk.

Keywords

Angina Pectoris Ischaemic Heart Disease Coronary Flow Reserve Isosorbide Dinitrate Coronary Spasm 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    A. Maseri, Expanding views on coronary artery disease: Role of vasospasm and other modulatory factors, in: “Atherosclerosis Reviews,” R. Hegyeli, ed., Raven Press, New York p.271 (1980).Google Scholar
  2. 2.
    A. Maseri, Pathogenetic mechanisms of angina pectoris: expanding views, Thomas Lewis Lecture, London, November 24, 1977. Br.Heart J. 43:648 (1980).PubMedCrossRefGoogle Scholar
  3. 3.
    A. Maseri, R. Mimmo, S. Chierchia, C. Marchesi, A. Pesola, and A. L’Abbate, Coronary artery spasm as a cause of acute myocardial ischaemia in man, Chest 68:625 (1975).CrossRefGoogle Scholar
  4. 4.
    A. Maseri, O. Parodi, S. Severi, and A. Pesola, Transient transmural reduction of myocardial blood flow, demonstrated by thallium-201 scintigraphy, as a cause of variant angina, Circulation 56:280 (1976).CrossRefGoogle Scholar
  5. 5.
    A. Maseri, A. L’Abbate, A. Pesola, A. M. Ballestra, M. Marzilli, S. Severi, G. Maltini, M. De Nes, O. Parodi, and A. Biagini, Coronary vasospasm in angina pectoris, Lancet 1:713 (1977).PubMedCrossRefGoogle Scholar
  6. 6.
    S. Chierchia, M. Guazzelli, C. Maggini, and A. Maseri, Absence of correlation of nocturnal angina with sleep stages, Circulation 57&58 (Suppl.II):753 (1978).Google Scholar
  7. 7.
    M. Guazzi, A. Polese, C. Fiorentina, F. Magrini, M. T. Olivari, and C. Bartorelli, Left ventricular performance and related haemodynamic changes in Prinzmetal’s variant angina pectoris, Br.Heart J. 33:84 (1971).PubMedCrossRefGoogle Scholar
  8. 8.
    M. Guazzi, A. Polese, C. Fiorentini, F. Magrini, M. T. Olivari, and C. Bartorelli, Left and right heart haemodynamics during spontaneous angina pectoris. Comparison between angina with S-T segment depression and angina with S-T segment elevation, Br.Heart J. 37:401 (1975).PubMedCrossRefGoogle Scholar
  9. 9.
    S. Chierchia, C. Marchesi, and A. Maseri, Evidence of angina not caused by increased myocardial metabolic demand and patterns of electrocardiographic and haemodynamic alterations during “primary” angina, in: “Primary and Secondary Angina Pectoris,” A. Maseri, G. A. Klassen, and M. Lesch, eds., Grune & Stratton, New York, p. 145 (1978).Google Scholar
  10. 10.
    L. Tavazzi, J. A. Salerno, M. Ray, G. Specchia, M. Chimienti, L. Angoli, S. De Servi, A. Mussini, and P. Bobba, Acute myocardial ischaemia induced by ergonovine maleate in patients with “primary” angina, in: “Primary and Secondary Angina Pectoris,” A. Maseri, G. A. Klassen, M. Lesch, eds., Grune & Stratton, New York, p.247 (1978).Google Scholar
  11. 11.
    G. H. Mudge Jr., W. Grossman, R. Millis, M. Lesch, and E. Braunwald, Reflex increase in coronary vascular resistance in patients with ischaemic heart disease, N.Engl.J.Med. 295:1333 (1976).PubMedCrossRefGoogle Scholar
  12. 12.
    H. Yasuc, S. Omote, A. Takazawa, and S. Tanaka, Circadian variation of exercise capacity in patients with Prinzmetal’s variant angina: role of exercise-induced coronary arterial spasm, Circulation 59:938 (1979).CrossRefGoogle Scholar
  13. 13.
    G. Specchia, S. De Servi, C. Falcone, E. Bramucci, L. Ango lie, A. Mussini, G. P. Marinoni, C. Montemartini, and P. Bobba, Coronary arterial spasm as a cause of exercise induced ST-segment elevation in patients with variant angina, Circulation 59:948 (1979).PubMedCrossRefGoogle Scholar
  14. 14.
    C. Brunelli, M. Lazzari, I. Simonetti, A. L’Abbate, and A. Maseri, Variable threshold of exertional angina: a clue to a vasospastic component, European Heart J. Vol. II, p. 155 (1981).Google Scholar
  15. 15.
    A. Maseri, S. Severi, M. De Nes, A. L’Abbate, S. Chierchia, M. Marzilli, A. M. Ballestra, O. Parodi, A. Biagini, and A. Distante, “Variant” angina: One aspect of a continuous spectrum of vasospastic myocardial ischaemia. Pathogenetic mechanisms, estimated incidence and clinical and coronary arteriographic findings in 138 patients, Am.J.Cardiol. 42:1019 (1978).PubMedCrossRefGoogle Scholar
  16. 16.
    S. Chierchia, A. Maseri, I. Simonetti, and C. Brunelli, O2 myocardial extraction in angina at rest. Evidence of a primary reduction of blood supply, Circulation 55,56 (Suppl. III):37 (1977).Google Scholar
  17. 17.
    S. Chierchia, C. Brunelli, I. Simonetti, M. Lazzari, and A. Maseri, Sequence of events in angina at rest: primary reduction in coronary flow, Circulation April (1980).Google Scholar
  18. 18.
    O. Parodi, N. Uthurralt, S. Severi, W. Bencivelli, C. Michelassi, and A. Maseri, Transient reduction of regional myocardial perfusion during angina at rest with ST segment depression or normalization of negative T waves (Submitted for publication).Google Scholar
  19. 19.
    J. Mellor, A. Pichard, and S. Dack, Coronary arterial spasm in Prinzmetal’s angina: a proved hypothesis, Am.J.Cardiol. 37:938 (1976).CrossRefGoogle Scholar
  20. 20.
    L. D. Hillis and E. Braunwald, Coronary artery spasm, N.Engl. J.Med. 299:695 (1978).PubMedCrossRefGoogle Scholar
  21. 21.
    J. Figueras, B. N. Singh, W. Ganz, Y. Charuzi, and H. J. C. Swan, Mechanisms of rest and nocturnal angina: observations during continuous haemodynamic and electrocardiographic monitoring, Circulation 59:955 (1979).PubMedCrossRefGoogle Scholar
  22. 22.
    M. E. Bertrand, C. Laisne, J. M. Lefebvre, A. Carre, H. Warembourg, and J. Lekieffre, Le spasme des arteres coronaires, Arch.Mal Coeur 70,1233 (1977).PubMedGoogle Scholar
  23. 23.
    M. Bory, M. Benichou, P. Dijiane, A. Egre, and A. Serradimigni, Angor de Prinzmetal et spasme arteriel coronarien, Arch. Mal Coeur 73,7 p.825 (1980).Google Scholar
  24. 24.
    J. P. Delahaye and Ph. Gaspard, Le spasme coronarien, Revue generale et etude critique a propos de 87 observations personnelles d’angine de Prinzmetal, Lyon Medical 245 p. 123 (1981).Google Scholar
  25. 25.
    A. Maseri, Variant angina and coronary vasospasm: clues to a broader understanding of angina pectoris, Cardiovasc.Med. 4, p.647 (1979).Google Scholar
  26. 26.
    A. Maseri, A. L’Abbate, G. Baroldi, S. Chierchia, M. Marzilli, A. M. Ballestra, S. Severi, O. Parodi, A. Biagini, A. Distante and A. Pesola, Coronary vasospasm as a possible cause of myocardial infarction. A conclusion derived from the study of “preinfarction” angina, N.Engl.J.Med. 299:1271 (1978).PubMedCrossRefGoogle Scholar
  27. 27.
    A. Maseri, S. Chierchia, and A. L’Abbate, Pathogenetic mechanisms underlying the clinical events associated with atherosclerotic heart disease, Circulation 62 (Suppl.V) 3–13 (1980).Google Scholar
  28. 28.
    A. Maseri, Preface, “Primary and Secondary Angina Pectoris,” eds., G. A. Klassen, A. Maseri, and M. Lesch, Grune & Stratton, New York, p.xiii (1978).Google Scholar
  29. 29.
    J. F. Mustard, Reversible platelet aggregation and myocardial ischaemia, Circulation 29 (Suppl.III) 111–130 (1964).Google Scholar
  30. 30.
    W. Kubler, D. Opherk, H. Mehmel, D. Zebe, and W. Maurer, Significance of coronary reserve in patients with different forms of “ischaemic heart disease”. VIII World Congress of Cardiology, Tokyo, Abstract Book 1, p. 124 (1978).Google Scholar
  31. 31.
    T. N. James, Pathology of small coronary arteries, Am.J.Cardiol. 30:679 (1967).CrossRefGoogle Scholar
  32. 32.
    P. J. Richardson, G. Jackson, E. G. J. Olsen, and S. Oram, Angina pectoris with normal coronary arteriograms: a metabolic problem? in: “Primary and Secondary Angina Pectoris,” A. Maseri, G. A. Klassen, and M. Lesch, eds., Grune & Stratton, New York, p.3 (1978).Google Scholar
  33. 33.
    T. N. James, Angina without coronary disease (sic), Circulation 42:18y (1970).CrossRefGoogle Scholar
  34. 34.
    D. E. Gregg and J. L. Bedynec, Compensatory changes in the heart during progressive coronary artery stenosis, in: “Primary and Secondary Angina Pectoris,” A. Maseri, G. A. Klassen, and M. Lesch, eds., Grune & Stratton, New York, p.3 (1978).Google Scholar
  35. 35.
    R. Lambert, D. S. Hess, and R. J. Bache, Effect of exercise on perfusion of collateral-dependent myocardium in dogs with chronic coronary artery occlusion, J.Clin.Invest. 59:1(1977).PubMedCrossRefGoogle Scholar
  36. 36.
    P. K. Sturzenhofecker, P. Peters, L. Gornandt, and H. Roskam, Coronary artery spasm combined with walk-through phenomenon. A special type of Prinzmetal angina. Symposium on Coronary Arterial Spasm, Lille, November (1979).Google Scholar
  37. 37.
    S. J. Schang Jnr., and C. J. Pepine, Transient asymptomatic S-T segment depression during daily activity, Am.J.Cardiol. 38:396 (1977).CrossRefGoogle Scholar
  38. 38.
    A. P. Selwyn, K. M. Fox, D. Oakley, H. J. Dargie, and J. P. Shillingford, Myocardial ischaemia in patients with angina pectoris, Br.Med.J. 2:1594–1596 (1979).CrossRefGoogle Scholar
  39. 39.
    T. B. Berndt, J. Fitzgerald, D. C. Harrison, and J. S. Schroeder, Hemodynamic changes at the onset of spontaneous versus pacing-induced angina, Am.J.Cardiol. 39:784 (1977).PubMedCrossRefGoogle Scholar
  40. 40.
    A. Biagini, D. Rovai, A. Maseri, G. Mazzei, C. Carpeggiani, F. Aghini-Lombardi, and M. Lazzari, Comparison of the double product determined during angina at rest and during atrial pacing. Diagnostic significance, Trans.Eur.Soc.Cardiol. 1:51 (1978).Google Scholar
  41. 41.
    M. Pagani, S. F. Vatner, B. R. Gain, and E. Braunwald, Initial myocardial adjustments to a brief period of ischaemia and reperfusion in the conscious dog, Circ.Res. 43:83 (1978).PubMedCrossRefGoogle Scholar
  42. 42.
    D. R. Ricci, A. E. Orlick, P. W. Doherty, P. R. Cipriano, and D. C. Harrison, Reduction of coronary blood flow during coronary artery spasm occurring spontaneously and after provocation by ergonovine maleate, Circulation 57:392 (1978).PubMedCrossRefGoogle Scholar
  43. 43.
    J. S. Schroeder, J. L. Bolen, R. A. Quint, D. A. Clark, W. G. Hyden, C. B. Higgins, and L. Wesler, Provocation of coronary spasm with ergonovine maleate, Am.J.Cardiol. 40:487 (1977).PubMedCrossRefGoogle Scholar
  44. 44.
    R. C. Curry, C. J. Pepine, M. B. Sabom, R. L. Feldman, L. G. Christie, and C. R. Conti, Effects of ergonovine in patients with or without coronary artery disease, Circulation 56:803 (1977).PubMedCrossRefGoogle Scholar
  45. 45.
    A. Distante, A. Maseri, S. Severi, A. Biagini, and S. Chierchia, Management of vasospastic angina at rest with continuous infusion of isosorbide dinitrate, Am.J.Cardiol. 44:533 (1979).PubMedCrossRefGoogle Scholar
  46. 46.
    Y. Uchida, N. Yoshimoto, and S. Murao, Cyclic fluctuations in coronary blood pressure and flow induced by coronary artery constriction, Jap.Heart J. 454–464 (1975).Google Scholar
  47. 47.
    J. D. Folts, E. B. Crowell Jnr., and G. G. Rowe, Platelet aggregation in partially obstructed vessels and its elimination with aspirin, Circulation 54:365–370 (1976).PubMedCrossRefGoogle Scholar
  48. 48.
    C. K. Friedberg, Diseases of the Heart, 3rd Edition, Saunders, New York (1966).Google Scholar
  49. 49.
    R. N. MacAlpin, A. A. Kattus, and A. B. Alvaro, Angina pectoris at rest with preservation of exercise capacity: Prinzmetal’s variant angina, Circulation 47:946 (1973).PubMedCrossRefGoogle Scholar
  50. 50.
    A. Maseri, S. Severi, S. Chierchia, O. Parodi, and A. Biagini, Characteristics and pathogenetic mechanism of “primary” angina at rest, in: “Primary and Secondary Angina Pectoris,” A. Maseri, G. A. Klassen, and M. Lesch, eds., Grune & Stratton New York, p.265 (1978).Google Scholar
  51. 51.
    A. Distante, A. L’Abbate, A. Maseri, L. Londini, and C. Michelassi, Echocardiographic changes in vasospastic angina, in: “Echocardiography,” Ch. T. Lancce, ed., Martinus Nijoff Publishers, The Hague, p.119 (1979).Google Scholar
  52. 52.
    L. S. Gettes, Painless myocardial ischaemia, Chest 66:612 (1975).CrossRefGoogle Scholar
  53. 53.
    J. W. Hurst, and R. B. Logue, Arteries and veins, in: “The Heart,” McGraw-Hill, New York, p.904 (1966).Google Scholar
  54. 54.
    A. Biagini, C. Carpeggiani, M. G. Mazzei, R. Antonelli, C. Michelassi, A. L’Abbate, and A. Maseri, Transient coronary spasm as a cause of asymptomatic S-T segment and T wave changes during Holter monitoring, (Submitted for publication).Google Scholar
  55. 55.
    A. M. Dart, H. Alban-Davies, R. H. Lowndes, J. Dalal, M. Ruttley, and A. H. Henderson, Oesophageal spasm and angina: diagnostic value of ergometrine provocation, Eur.Heart J. (in press).Google Scholar
  56. 56.
    G. J. Davies, S. Chierchia, M. Myers, A. Maseri, and R. E. Steiner, Transient changes in left ventricular volume in acute myocardial ischaemia, Clinical Science 60:13 (1981).Google Scholar
  57. 57.
    J. E. Madias, The syndrome of variant angina culminating in acute myocardial infarction, Circulation 59:297–306 (1979).PubMedCrossRefGoogle Scholar
  58. 58.
    P. M. Richardson and M. S. Gotsman, Angiographic evidence of coronary embolism and resolution, S.Afr.Med.J. 45:805 (1971).PubMedGoogle Scholar
  59. 59.
    R. J. O’Reilly and R. D. Spellberg, Rapid resolution of coronary arterial emboli: myocardial infarction and subsequent normal coronary arteriograms, Ann.Int.Med. 81:348 (1974).PubMedCrossRefGoogle Scholar
  60. 60.
    Ph. B. Oliva and J. C. Breckenridge, Arteriographic evidence of coronary arterial spasm in acute myocardial infarction, Circulation 56:366 (1977).PubMedCrossRefGoogle Scholar
  61. 61.
    J. A. Trigano, G. Chiesa, and C. Diard, Alterations electrocardiographiques de type angor de Prinzmental en phase aigue d’infarctus du myocarde, Arch.Mal Coeur 70:901 (1977).PubMedGoogle Scholar
  62. 62.
    A. W. Branwood and G. L. Montgomery, Observations on the morbid anatomy of coronary artery disease, Scot.Med.J. 1:367 (1956).PubMedGoogle Scholar
  63. 63.
    D. M. Spain, V. A. Brades, A. Matero, and R. Tarter, Sudden death due to coronary atherosclerotic heart disease: age, smoking habits and recent thrombi, J.Am.Med.Ass. 207:1347 (1969).CrossRefGoogle Scholar
  64. 64.
    G. Baroldi, Acute coronary occlusion as a cause of myocardial infarct and sudden coronary heart death, Am.J.Cardiol. 16:859 (1965).PubMedCrossRefGoogle Scholar
  65. 65.
    W. C. Roberts, Coronary thrombosis and fatal myocardial ischaemia, Circulation 49:1 (1974).PubMedCrossRefGoogle Scholar
  66. 66.
    L. R. Erhardt, T. Lundman, and H. Mellstedt, Incorporation of 125I-labelled fibrinogen into coronary arterial thrombi in acute myocardial infarction in man, Lancet 1:387 (1973).PubMedCrossRefGoogle Scholar
  67. 67.
    W. H. Sewell, Coronary spasm as a primary cause of myocardial infarction: a preliminary report, Angiology 17:1 (1966).PubMedCrossRefGoogle Scholar
  68. 68.
    W. F. M. Fulton, Does coronary thrombosis cause myocardial infarction or vice versa? in: “Advanced Medicine,” 14:138–147, J. Weatherall ed., Royal Coll.Phys.London, Pitman Medical.Google Scholar
  69. 69.
    G. Baroldi, Dif f erent types of myocardial necrosis in coronary heart disease: a pathophysiologic review of the functional significance, Am.Heart J. 89:742 (1975).PubMedCrossRefGoogle Scholar
  70. 70.
    K. P. Rentrop, H. Blanke, and K. R. Karsch, Acute myocardial infarction intracoronary application of nitroglycerin and streptokinase, Clin.Cardiol. 2:354–363 (1979).PubMedGoogle Scholar
  71. 71.
    W. Ganz, N. Buchbinder, M. S. Marcus, A. Mondkar, J. Maddahi, Y. Charusi, M. C. Fishbein, R. Kass, A. Miyamoto, W. Shell, and H. J. C. Swan, Intracoronary thrombolysis in evolving myocardial infarction, Am.Heart J. (in press) (1981).Google Scholar
  72. 72.
    H. Huchard, Traite des maladies du coeur et des vaisseaux arteriosclerose, aortites, cardiopathies arterielles, angines de poitrine, Paris, p.466 (1889).Google Scholar
  73. 73.
    W. Osier, The Lumlcian lectures on angina pectoris II, Lancet 839–844 (1910).Google Scholar
  74. 74.
    L. Gallavardin, Les angines de poitrine, Paris, p.45 (1925).Google Scholar
  75. 75.
    H. Yasue, M. Youyama, H. Kato, S. Tanaka, and F. Akiyama, Prinzmetal’s variant form of angina as a manifestation of alpha-adrenergic receptor mediated coronary artery spasm: documentation by coronary arteriography, Am.Heart J. 91:148 (1976).PubMedCrossRefGoogle Scholar
  76. 76.
    D. L. Levene and M. R. Freeman, Alpha adrenoceptor-mediated coronary artery spasm, JAMA 236:1018–1022 (1976).PubMedCrossRefGoogle Scholar
  77. 77.
    D. R. Ricci, A. E. Orlick, P. R. Cipriano, D. F. Guthaner, and D. C. Harrison, Altered adrenergic activity in coronary arterial spasm: insight into mechanism based on study of coronary haemodynamics and the electrocardiogram, Am.J.Cardiol. 43:1073 (1979).PubMedCrossRefGoogle Scholar
  78. 78.
    D. Robertson, R. Robertson, A. Nies, J. Oates, and G. Friesinger, Variant angina pectoris: investigation of indexes of sympathetic nervous system function, Am.J.Cardiol. 43:1080 (1979).PubMedCrossRefGoogle Scholar
  79. 79.
    G. Arnulf, De la section du plexus pre-aortique: justification et technique, Press Med. 47:94 (1939).Google Scholar
  80. 80.
    M. E. Bertrand, J. M. Lablanche, M. Rousseau, H. Warenbourg, C. Stankowiak, and G. Loots, Surgical treatment of Prinzmetal’s variant angina. Utility of plexectomy associated with aortocoronary bypass, Circulation 61:877–882 (1980).PubMedCrossRefGoogle Scholar
  81. 81.
    O. Parodi, A. Maseri, and I. Simonetti, Management of unstable angina at rest by verapamil: a double blind cross-over study in CCU, Br.Heart J. 41:167 (1979).PubMedCrossRefGoogle Scholar
  82. 82.
    J. E. Muller and S. J. Gunter, Nifedipine therapy for Prinzmetal’s angina, Circulation 57:137 (1978).PubMedCrossRefGoogle Scholar
  83. 83.
    M. Previtali, J. A. Salerno, and L. Tavazzi, Treatment of angina at rest with nifedipine: a short term controlled study, Am.J.Cardiol. 45:825–830 (1980).PubMedCrossRefGoogle Scholar
  84. 84.
    P. Maurice, B. Lancelin, and J. L. Guermonprez, Traitment de l’anger de Prinzmetal par le diltiazem, 8th Congres Europeen de Cardiologie, Paris, p.127 abstract, (1980).Google Scholar
  85. 85.
    S. Chierchia, F. Crea, G. Gasperetti, R. De Caterina, and A. Maseri, Effects of alpha-adrenergic blockade with phen-tolamine in vasospastic angina, in: “Alpha Blocking Agents: Experimental and Clinical Pharmacology,” Masson, Paris (in press).Google Scholar
  86. 86.
    S. Chierchia, R. De Caterina, C. Brunelli, F. Crea, C. Patrono, and A. Maseri, Low dose aspirin prevents thromboxane A2 synthesis by platelets but not attacks of Prinzmetal’s angina, Circulation (abstract) 62 (Suppl.)III–215 (1980).Google Scholar
  87. 87.
    S. Chierchia, F. Crea, W. Bernini, R. De Caterina, and A. Maseri, Results of prostacyclin (PG12) continuous infusion in angina at rest (abstract) Circulation 62 (Suppl.III):310 (1980).Google Scholar
  88. 88.
    A. Jouve, La place de la Medecine Psychosomatique en cardiologie, Coeur et Med.Int. VII:327–331 (1968).Google Scholar
  89. 89.
    R. N. MacAlpin, Correlation of the location of coronary arterial spasm with the lead distribution of ST segment elevation during varian angina, Am.Heart J. 99:555–564 (1980).PubMedCrossRefGoogle Scholar
  90. 90.
    S. Severi, G. J. Davies, A. Maseri, P. Marzullo, and A. L’Abbate, Long term prognosis of variant angina with medical treatment, Am. J. Cardiol. 46:226–232 (1980).PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 1984

Authors and Affiliations

  • Attilio Maseri
    • 1
  1. 1.Hammersmith HospitalRoyal Postgraduate Medical SchoolLondonUK

Personalised recommendations