Cath Lab Digest - September 2007 - (Page 27)

27 That our patient should manifest this systemic “Raynaud-Prinzmetal syndrome” seems more plausible than the simultaneous co-existence of two independent conditions. due to concerns of inducing refractory CV. Thus, given the acute infarct setting, pharmacologic provocation was not performed in our case. CV occurs predominately in the RCA. This phenomenon is likely attributable to a muscular band surrounding the RCA ostium.3 Occasionally CV, either spontaneous or catheter-induced, can resemble a fixed atherosclerotic stenosis during coronary angiography. When encountered, this question is usually easily resolved by intracoronary administration of nitroglycerine through the catheter.3 A case of simultaneous left main/saphenous vein graft spasm has been reported. 4 Clearly, a global “pro-spasmodic” milieu can exist, even involving a denervated venous conduit. Moreover, extra-cardiac extension of this global spasmodic state was observed by Myers and coauthors in a woman with acute anterior wall infarction after cocaine abuse. She presented with severe left main and femoral artery spasm. Fortunately, both responded to nitroglycerine and diltiazem.5 Treatment of Prinzmetal’s angina (PA) is overwhelmingly medical. Calcium antagonist and nitrate therapy should be maximized to tolerability. It is curious that our patient may have experienced severe CV despite chronic nifedipine therapy. Perhaps the overwhelming catecholamine surge from stress of the work situation, coupled with her hyper-anxious personality, was sufficient to overcome the medication’s vasodilatory effects. Overall, these patients have excellent long-term prognoses. The role of stenting for this condition remains controversial. Rarely, in refractory cases, coronary bypass surgery has been performed, usually with unpredictable results. Competitive flow from preserved inter-spasm native coronary flow can lead to graft occlusion.6 Complete denervation by plexectomy has also been described for severe cases of variant angina.7 Raynaud originally described the phenomenon of cold-triggered arterial vasospasm, usually involving the digital circulation. He postulated an exaggerated adrenergically-induced arterial spasm reflex. Multiple systemic illnesses, specifically collagen-vascular disorders, have been associated with this condition. There is a 5-fold female predominance, with usual onset between the ages of 20 to 40. Finger manifestation is the rule, with rare involvement of the toes. The classic triad of blanching, cyanosis, and erythema can be observed during cold exposure followed by re-warming. Conservative treatment may be sufficient in the majority of Raynaud’s cases.8 Warm gloves, socks, and shoes can be quite beneficial. Medications are re-served for moderate to severe cases. As with PA, vasodilating agents such as calcium antagonists are the mainstay of therapy. Long-acting nitrates have also been used in conjunction with these agents. In a medication-refractory case, surgical sympathectomy may provide impressive, but often transient, symptomatic relief.8 To assess the possible relationship of PA and Raynaud’s Phenomenon (RP), Koh and colleagues performed digital blood flow dynamic studies (assessment of RP) in 3 groups of patients with CV (group I), documented coronary disease (group II), and normal controls (group III). No difference in prevalence of Raynaud’s findings were seen between group I and the collective groups of II and III. They concluded that variant angina, at least in Korean patients, may not be linked to systemic vasospasm.9 Similarly, in their digital flow dynamic series, Nakamura and co-investigators reported no association between RP and CV or ischemic heart disease.10 Another study evaluated the effects of cold provocation on thallium-201 myocardial perfusion scintigraphy. While 11 of 13 patients demonstrated cold-induced myocardial ischemia, there was no correlation with history of RP.11 Thus, while the seemingly logical relationship between RP and PA has been postulated, a definitive association has not been shown. Nonetheless, that our patient should manifest this systemic “Raynaud-Prinzmetal syndrome” seems more plausible than the simultaneous co-existence of two independent conditions. Future investigations will likely elucidate the potential link between these two similar maladies. ■ Dr. Chen can be contacted at chenjackapollo@yahoo.com Left main and saphenous vein graft spasm: an unusual association. Intern J Cardiol 2005;99:133-134. 5. Myers GH, Hansen TH, Jain A. Left main coronary artery and femoral artery vasospasm associated with cocaine use. Chest 1991;100:257-258. 6. Ng WL, Sim EKW, Yeo TC, et al. Surgery for left main spasm. Is it indiInternat J Cardiol cated?. 1996;54:213-216. 7. Bertrand ME, Lablanche JM, Tilmant PY, et al. Complete denervation of the heart (autotransplantation) for treatment of severe refractory coronary spasm. Am J Cardiol 1981;47:13751378. 8. Creager MA, Dzau VJ. Vascular diseases of the extremities. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, ed. Harrison’s Principles of Internal Medicine, 14th Ed. New York: McGraw-Hill Health Professions Division, 1998:1398-1406. 9. Koh KK, Kim SH, Lee KH, et al. Does prevalence of migraine and Raynaud’s phenomenon also increase in Korean patients with proven variant angina? Intern J Cardiol 1995;51:37-46. 10. Nakamura Y, Shinozaki N, Hirasawa M, et al. Prevalence of migraine and Raynaud’s phenomenon in Japanese patients with vasospastic angina. Japan Circ J 2000;64:239-242. 11. Stefenelli T, Sochor H, Slama B, et al. Transient myocardial perfusion abnormalities during cold provocation test in patients with arterial hyperreactivity. Zeitschrift fur Kardiologie 1991;80:622-626. References 1. Prinzmetal M, Kennamer R, Merliss R, et al. Angina pectoris. I. A variant form of angina pectoris; preliminary report. Am J Med 1959;27:375-388. 2. Bertrand ME, LaBlanche JM, Tilmant PY, et al. Frequency of provoked coronary arterial spasm in 1089 consecutive patients undergoing coronary arteriography. Circulation 1982;65:12991306. 3. Chen JP. Iatrogenic left main coronary stenosis? Don’t rush to operate. Cath Lab Digest 2007;15:1,8-12. 4. Porto I, Burzotta F, Mongiardo R, et al. http://www.merit.com http://www.merit.com

Table of Contents Feed for the Digital Edition of Cath Lab Digest - September 2007

St. Dominic Hospital The Genous Bio-engineered R Stent Percutaneous Treatment of Peripheral Arterial Chronic Total Occlusions: Device Options and Clinical Outcomes Contents Clinical Editor’s Corner Percutaneous Revascularization of Peripheral Chronic Total Occlusion — Which Patients, Why, and How? Myocardial Infarction and Syncope: A Manifestation of the “Raynaud-Prinzmetal Syndrome”? Essential Technical Components of the Transradial Approach If You Build It, Will They Come? Evidence-Based Medicine with Drug-Eluting Stents Back to School: The Value of Education in Cardiovascular Services The ACVP Standards and Competencies: Are You Using Them Effectively? What Do You Think? My Experience with Fibromuscular Dysplasia and Stroke A Brief Review of Fibromuscular Dysplasia Letter to the Editor A Look at On-the-Job Training: Perceptions, Reality and Our Profession Doing the Wave: Inventory Management with RFID The Ten-Minute Interview with… Paul Pinsker, RCIS CLD’s Annual Salary Survey Harrisburg Area Community College Volunteer Survey CEU Education Center SICP* Section Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Clinical & Industry News

Cath Lab Digest - September 2007

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