Unrecognized coronary vasospasm in patients referred for percutaneous coronary intervention: Intracoronary nitroglycerin, the forgotten stepchild of cardiovascular guidelines.
OBJECTIVE
The goal of this study was to demonstrate the importance of intracoronary nitroglycerin (IC NTG) administration during diagnostic coronary angiography and prior to percutaneous coronary intervention (PCI).


BACKGROUND
PCI has been a mainstay treatment for patients with symptomatic coronary artery disease. While current guidelines emphasize the importance of periprocedural antithrombotic medications, they fail to mention the use of nitroglycerin prior to PCI.


METHODS
Retrospective chart and angiographic review was performed to identify patients referred for PCI who had significant angiographic stenoses that resolved after administration of IC NTG.


RESULTS
The study group consisted of 6 patients (3 men, 3 women) with mean age 52 ± 4years (range 46-57 years). All had anginal symptoms and significant (>70%) stenosis on diagnostic coronary angiography. None had documented ST segment elevation. The median interval between diagnostic and staged PCI procedures was 3 days. IC NTG was not administered to any of the patients at the time of diagnostic coronary angiography. In each case, repeat coronary angiography following administration of IC NTG (155 ± 46 mcg) before planned PCI demonstrated resolution of the target stenosis. PCI was deferred and all patients were successfully managed medically.


CONCLUSIONS
Coronary artery spasm is an under-recognized cause of chest pain in patients with significant angiographic lesions. Coronary spasm should be suspected especially in younger patients (less than 60 years old) with apparent single vessel disease. IC NTG should be routinely administered during diagnostic angiography and before PCI to avert unnecessary coronary interventions. © 2017 Wiley Periodicals, Inc.
Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
Alec
A
Vishnevsky
Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
Howard M
HM
Julien
Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
David L
DL
Fischman
Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
Paul
P
Walinsky
Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
J
J
David Ogilby
Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
Nicholas J
NJ
Ruggiero
Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
Babu
B
Jasti
Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
Michael P
http://orcid.org/0000-0002-5259-1178
MP
Savage
D000066491:Clinical Decision-Making; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000503:physiopathology; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000503:physiopathology; D003329:Coronary Vasospasm / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000503:physiopathology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D005996:Nitroglycerin / Q000008:administration & dosage* / Q000009:adverse effects; D062645:Percutaneous Coronary Intervention / Q000592:standards; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D012017:Referral and Consultation; D012189:Retrospective Studies; D016896:Treatment Outcome; D019564:Unnecessary Procedures; D014665:Vasodilator Agents / Q000008:administration & dosage* / Q000009:adverse effects
D014665:Vasodilator Agents; D005996:Nitroglycerin
coronary angiography; coronary artery disease; coronary spasm; nitroglycerin; percutaneous coronary intervention