2004 Circ J 改善ST段抬高MI微血管痉挛病例报告(冠脉)

depression during exercise or atrial pacing despite normal coronary angiograms are diagnosed as ‘syndrome X’.3,4 From the therapeutic point of view, calcium channel block-ers are extremely effective for epicardial coronary spasm, but have limited efficacy in patients with syndrome X.5,6 Several cases with spontaneous electrocardiographic (ECG) changes and normal coronary angiograms have been recently reported in Japan7,8and this rare phenome-non is thought to be caused by coronary microvascular spasm. Very recently, it has been suggested that coronary microvascular spasm may also contribute to the anginal pain of vasospastic angina9and syndrome X.10We describe a case of spontaneous microvascular spasm during coro-nary angiography with ST segment elevation for which intracoronary administration of nicorandil was extremely useful.Case ReportA 64-year-old man with a history of previous coronary intervention of the left anterior descending artery was admitted because of recurrent chest pain at rest. Physical examination on admission showed a blood pressure of 124/60mmHg, a heart rate of 68beats/min and no abnor-malities of the chest and abdomen. Admission ECG at rest showed no significant ischemic changes; ECG during exer-cise was not performed. After obtaining written informed consent, cardiac catheterization was performed. Left ven-Circulation Journal Vol.68, March 2004ECG showed ST segment elevation in leads II, III and aV F (Fig1). Immediate right coronary angiography revealed no significant coronary artery stenosis, but markedly delayed contrast medium washout. The thrombolysis-in-myocar-dial-infarction (TIMI) frame count11,12from the ostium to the distal landmark increased to 116 (Fig2). Because the chest pain, ST segment elevation and delayed washout of the right coronary artery continued for 2min after intra-coronary administration of nitroglycerin, we administrated 2mg of nicorandil into the right coronary artery. One minute later, the chest pain and ST segment elevation disappeared. Repeat right coronary angiography revealed normal contrast medium washout, and the TIMI frame count decreased to 42 (Fig3). The patient was diagnosed as having microvascular spasm for which intracoronary administration of nicorandil was extremely useful.DiscussionThere are a few reports of patients experiencing sponta-neous microvascular spasm during coronary angiography. Yamagishi et al7reported a case of delayed contrast medi-um washout in the left anterior descending artery and ST segment elevation. As the onset of chest pain occurred more than 10min after the administration of acetylcholine into the right coronary artery, they believed that microvas-cular spasm in the left anterior descending artery occurred spontaneously and was not induced by intracoronary administration of acetylcholine. Mohri et al8reported 2 cases with spontaneous microvascular spasm as evidenced by the typical chest pain during catheterization and which was associated with ST segment elevation in one patient and ST segment depression in the other.In the current case, we did not use either ergonovine or acetylcholine to induce coronary spasm during coronaryCirc J2004; 68:267–269268KURISU S et al.Circulation Journal Vol.68, March 2004angiography. An increase in demand for myocardial oxygen was unlikely to have caused myocardial ischemia because the rate –pressure product did not change during ST segment elevation. In addition, it is unlikely that the contrast medium was associated with the myocardial ischemia because the ECG changes did not occur during left coronary angiography. We could not perform left coro-nary angiography during the ST segment elevation in leads II, III and aV F , but observed markedly delayed contrast medium washout in the right coronary artery, which sug-Fig 1.Serial electrocardiograms (ECGs) during coronary angiography. ST segment elevation was observed in leads II,III and aV F even after intracoronary administration of nitroglycerin. Intracoronary administration of nicorandil resolved the ECGs change.Fig 2.Left ventriculography revealed normal wall motion, and coronary angiography revealed no significant coronary artery stenosis. Contrast medium, which used for the first image of the right coronary artery, remained in the mid portion.The second image of the right coronary artery revealed markedly delayed contrast medium washout, and the TIMI frame count increased to 116. Numbers show TIMI frame count from the ostium.Fig 3.Intracoronary administration of nicorandil attenuated the delayed washout of the right coronary artery, and the TIMI frame count decreased to 42.Numbers show TIMI frame count from the ostium.269Nicorandil in Microvascular SpasmCirculation Journal Vol.68, March 2004gested that the microvascular spasm occurred spontaneous-ly in the right coronary artery. It has been demonstrated that nitroglycerin produces a dose-related dilation of coro-nary microvessels greater than 200 m in diameter and has little or no effect on smaller coronary microvessels. In the current case, intracoronary administration of nitroglycerin did not attenuate chest symptoms or the ST segment eleva-tion, suggesting that the major responsible site was vessels of less than 200 m in diameter.13Nicorandil is a hybrid of a nitrate and an ATP-sensitive potassium channel opener,and has a potent vasodilator effect on coronary arteries.14–17It has been shown that coronary microvascular resistance is largely regulated by ATP-sensitive potassium channels. Ito et al recently reported 2 patients in whom intracoronary administration of diltiazem or nicorandil markedly attenu-ated delayed contrast medium washout with ST segment depression refractory to nitroglycerin.18We have shown that intracoronary administration of nicorandil can attenu-ate spontaneous microvascular spasm even with ST seg-ment elevation. It is an important but unresolved question why the ECG reveals ST segment elevation in one patient with microvascular spasm and ST segment depression in the other. It may depend on the degree of myocardial ischemia caused by the microvascular spasm or the micro-vascular level at which the spasm occurs. Further clinical studies and basic experiments are required to clarify the mechanism. In conclusion, nicorandil should be considered in patients with microvascular spasm.References1.Maseri A, Pesola A, Marzilli M, Severi S, Parodi O, L’Abbate A, et al. Coronary vasospasm in angina pectoris. Lancet 1977; 1:713–718.2.Ozaki Y, Keane D, Serruys PW. Progression and regression of coro-nary stenosis in the long-term follow-up of vasospastic angina.Circulation 1995; 92:2446–2456.3.K aski JC, Crea F, Nihoyannopoulus P, Hacket D, Maseri A.Transient myocardial ischemia during daily life in patients with syndrome X. Am J Cardiol 1986; 58:1242–1247.4.Maseri A, Crea F, Kaski JC, Crake T. Mechanisms of angina pectoris in syndrome X. J Am Coll Cardiol 1991; 17:499–506.nza GA, Colonna G, Pasceri V, Maseri A. 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