title: Vasotonic angina: a spectrum of ischemic syndromes involving functional abnormalities of the epicardial and microvascular coronary circulation.
abstract: OBJECTIVE
  The present study was undertaken to investigate the response of large and small coronary arteries in a subgroup of patients with no or minimal coronary artery disease found to have objective signs of myocardial ischemia.
  
  
  BACKGROUND
  Many patients apparently have normal coronary arteries despite abnormal electrocardiographic (ECG) changes during spontaneous anginal attacks or exercise stress testing.
  
  
  METHODS
  Twenty-five patients with no or minimal (< 30% stenosis) coronary artery disease were chosen from a pool initially selected on the basis of spontaneous anginal attacks and ST segment shifts in the anterior leads. Of these, 10 were grouped as having variant angina (at least one episode of ST elevation) and the remaining 15 as having syndrome X (exercise-induced anginal pain, ST depression and reversible thallium abnormalities). Data were compared with those obtained in 10 patients with stable angina and documented coronary artery disease. Eighteen patients with supraventricular arrhythmias and normal coronary arteries served as control patients. Patients showing focal spasm during ergonovine testing were not included in the subsequent angiographic analysis. Great cardiac vein blood flow, aortic pressure and changes in coronary artery diameter were measured at rest and 2 to 4 min after hyperventilation in the remaining study group. The same procedure was repeated after sublingual administration of 0.3 mg of nitroglycerin in eight patients (four with syndrome X and four with variant angina).
  
  
  RESULTS
  Hyperventilation induced diffuse epicardial coronary diameter reduction, which was marginal in control patients (9 +/- 4%) and those with coronary artery disease (5 +/- 3%) but severe (p < 0.001) in those with variant angina (28 +/- 14%) or syndrome X (25 +/- 13%). Concomitant determination of coronary blood flow showed significant (p < 0.001) decreases in those with variant angina (25 +/- 11%) and syndrome X (28 +/- 10%) but not in control patients (5 +/- 8%) or those with coronary artery disease (4 +/- 5%). Changes in great cardiac vein blood flow during hyperventilation were similar before and after nitroglycerin.
  
  
  CONCLUSIONS
  These findings indicate that vasoconstrictor stimuli may trigger a diffuse abnormal response of both epicardial and resistance vessels in some patients with chest pain and angiographically normal coronary arteries. Patients showing such diffuse vasoconstrictor abnormalities are suggested to have a single pathogenetic entity with a spectrum of ECG manifestations ranging from ST depression to ST elevation.
authors.affiliation: Institute of Patologia Medica III, University of Bologna, Italy.
authors.forename: R
authors.initials: R
authors.lastname: Bugiardini
authors.forename: A
authors.initials: A
authors.lastname: Pozzati
authors.forename: F
authors.initials: F
authors.lastname: Ottani
authors.forename: G L
authors.initials: GL
authors.lastname: Morgagni
authors.forename: P
authors.initials: P
authors.lastname: Puddu
mesh_terms: D000328:Adult; D000787:Angina Pectoris / Q000503:physiopathology*; D000788:Angina Pectoris, Variant / Q000503:physiopathology; D016022:Case-Control Studies; D017023:Coronary Angiography; D003326:Coronary Circulation / Q000502:physiology*; D003331:Coronary Vessels / Q000503:physiopathology*; D005260:Female; D006801:Humans; D008297:Male; D008833:Microcirculation / Q000503:physiopathology; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000503:physiopathology; D010496:Pericardium / Q000503:physiopathology; D013577:Syndrome; D014661:Vasoconstriction