Sechtem

Sebastian Kubik, Stephan Hill, Tim Schufele, Heiko Mahrholdt, Juan Carlos Kaski and Udo
Peter Ong, Anastasios Athanasiadis, Gabor Borgulya, Ismail Vokshi, Rachel Bastiaenen,
Unobstructed Coronary Arteries
Acetylcholine Provocation Testing Among 921 Consecutive White Patients With
Clinical Usefulness, Angiographic Characteristics, and Safety Evaluation of Intracoronary
Print ISSN: 0009-7322. Online ISSN: 1524-4539
Copyright 2014 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Circulation
doi: 10.1161/CIRCULATIONAHA.113.004096
2014;129:1723-1730; originally published online February 26, 2014; Circulation.
http://circ.ahajournals.org/content/129/17/1723
World Wide Web at:
The online version of this article, along with updated information and services, is located on the

http://circ.ahajournals.org//subscriptions/
is online at: Circulation Information about subscribing to Subscriptions:

http://www.lww.com/reprints
Information about reprints can be found online at: Reprints:

document. Permissions and Rights Question and Answer this process is available in the
click Request Permissions in the middle column of the Web page under Services. Further information about
Office. Once the online version of the published article for which permission is being requested is located,
can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Circulation in
Requests for permissions to reproduce figures, tables, or portions of articles originally published Permissions:
by guest on May 1, 2014 http://circ.ahajournals.org/ Downloaded from by guest on May 1, 2014 http://circ.ahajournals.org/ Downloaded from
1723
S
ince its inaugural description in 1959,
1
coronary artery
spasm has been recognized as an important cardiac con-
dition that can lead to myocardial ischemia and angina pecto-
ris in patients with obstructive coronary artery disease and in
those without, as well.
2
Coronary spasm can be the cause for
myocardial infarction
3
and ventricular arrhythmias,
4
and cor-
onary spasm has also been shown to occur on the level of the
microcirculation.
5
It has been suggested that coronary spasm
is more prevalent among Asian in comparison with white
populations
6,7
and that whites more often have focal coro-
nary spasm associated with an atherosclerotic plaque rather
than diffuse spasm in the distal parts of the epicardial ves-
sels.
8
Moreover, it has been hypothesized that the frequency
of coronary spasm is on the decrease in the Western world.
9

However, provocation testing using intracoronary acetyl-
choline administration in search of coronary spasm is rarely
performed in daily clinical routine in the United States and
Europe. In this study, we sought to assess the frequency of epi-
cardial and microvascular coronary spasm, the angiographic
characteristics, and the safety of intracoronary acetylcholine
(ACH) provocation testing (ACH test) in a contemporary
cohort of 921 consecutive white patients with unobstructed
coronary arteries.
Editorial see p 1717
Clinical Perspective on p 1730
BackgroundCoronary spasm can cause myocardial ischemia and angina in patients with and those without obstructive
coronary artery disease. However, provocation tests using intracoronary acetylcholine administration are rarely performed
in clinical routine in the United States and Europe. Thus, we assessed the clinical usefulness, angiographic characteristics,
and safety of intracoronary acetylcholine provocation testing in white patients with unobstructed coronary arteries.
Methods and ResultsFrom September 2007 to June 2010, a total of 921 consecutive patients (362 men, mean age
6212years) who underwent diagnostic angiography for suspected myocardial ischemia and were found to have
unobstructed coronary arteries (no stenosis 50%) were enrolled. The intracoronary acetylcholine provocation testing
was performed directly after angiography according to a standardized protocol. Three hundred forty-six patients (35%)
reported chest pain at rest, 222 (22%) reported chest pain on exertion, 238 (24%) reported a combination of effort and
resting chest pain, and 41 (4%) presented with troponin-positive acute coronary syndrome. The overall frequency of
epicardial spasm (>75% diameter reduction with angina and ischemic ECG shifts) was 33.4%, and the overall frequency
of microvascular spasm (angina and ischemic ECG shifts without epicardial spasm) was 24.2%. Epicardial spasm was
most often diffuse and located in the distal coronary segments (P<0.01). No fatal or irreversible nonfatal complications
occurred. However, 9 patients (1%) had minor complications (nonsustained ventricular tachycardia [n=1], fast paroxysmal
atrial brillation [n=1], symptomatic bradycardia [n=6], and catheter-induced spasm [n=1]).
ConclusionsEpicardial and microvascular spasm are frequently found in white patients with unobstructed coronary arteries.
Epicardial spasm is most often diffuse and located in the distal coronary segments. The intracoronary acetylcholine
provocation test is a safe technique to assess coronary vasomotor function. (Circulation. 2014;129:1723-1730.)
Key Words: acetylcholine

complications

coronary vasospasm

microvascular angina.
2014 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.113.004096
Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz.
Received May 28, 2013; accepted January 28, 2014.
From the Robert-Bosch-Krankenhaus, Department of Cardiology, Stuttgart, Germany (P.O., A.A., S.H. T.S., H.M., U.S.); St Georges University of
London, Clinical Trials Unit, London, United Kingdom (G.B.); and Cardiovascular Sciences Research Centre, St Georges University of London, London,
United Kingdom (I.V., R.B., S.K., J.C.K.).
*Drs Kaski and Sechtem contributed equally to this work as last authors.
Correspondence to Peter Ong, MD, Robert-Bosch-Krankenhaus, Department of Cardiology, Auerbachstr. 110, 70376 Stuttgart, Germany. E-mail
Peter.Ong@rbk.de
Clinical Usefulness, Angiographic Characteristics, and Safety
Evaluation of Intracoronary Acetylcholine Provocation
Testing Among 921 Consecutive White Patients With
Unobstructed Coronary Arteries
Peter Ong, MD; Anastasios Athanasiadis, MD; Gabor Borgulya, MD, MSc;
Ismail Vokshi, MBBS; Rachel Bastiaenen, MBBS; Sebastian Kubik; Stephan Hill, MD;
Tim Schufele, MD; Heiko Mahrholdt, MD; Juan Carlos Kaski MD, DSc*; Udo Sechtem, MD*
Coronary Heart Disease
by guest on May 1, 2014 http://circ.ahajournals.org/ Downloaded from
1724 Circulation April 29, 2014
Methods
Patients
From September 2007 to June 2010, a total of 921 consecutive
patients (362 men, mean age 6212 years) who underwent diagnostic
coronary angiography for suspected myocardial ischemia and were
found to have unobstructed coronary arteries (no epicardial stenosis
50%) were included in the study. ACH test was performed directly
after diagnostic coronary angiography. Subjects were excluded and
the provocation test was not performed if patients had severe chronic
obstructive pulmonary disease or impaired renal function (creatinine
>2.0 mg/dL), or if spontaneous spasm was observed. The follow-
ing information was recorded for every patient: clinical presentation
(chest pain at rest, chest pain on exertion, or a combination of both);
previous history of obstructive coronary artery disease including pre-
vious coronary stent implantation or coronary artery bypass surgery;
cardiovascular risk factors including hypertension, diabetes mellitus,
hypercholesterolemia, a history of smoking, and a positive family his-
tory for cardiovascular events (myocardial infarction or stroke in a
parent or sibling); presentation with troponin-positive acute coronary
syndrome (ST-segment elevation myocardial infarction or nonST-
segment myocardial infarction); results of noninvasive stress tests
for myocardial ischemia (a positive response was dened as transient
ischemic ECG changes 0.1 mV in at least 2 contiguous leads, 80 ms
after the J point, and reproduction of angina during the stress test).
Furthermore, the degree of narrowing along the epicardial vessels
was quantied and categorized (0%20% and 21%49% narrowing).
Patients with a previous history of obstructive coronary artery dis-
ease had all undergone revascularization and were eligible because
repeated coronary angiography owing to recurrent symptoms and the
suspicion of progress of coronary artery disease did not reveal any
relevant epicardial stenosis.
Study Protocol
The study protocol complied with the Declaration of Helsinki and
the study was approved by the institutional review committee. All
patients gave written informed consent before angiography. All
patients in the study underwent intracoronary provocation with ACH
in accordance to a standardized protocol
10,11
immediately after diag-
nostic angiography. Cardiovascular medications (-blockers, calcium
channel blockers, and nitrates) were discontinued 48 hours before
coronary angiography. Sublingual glyceryl trinitrate administration
was permitted for the relief of chest pain at all times. However, none
of the patients required this treatment <4 hours before angiography.
Heart rate, blood pressure, and the 12-lead ECG were continuously
monitored during ACH testing. Ischemic ECG changes were dened
as transient ST-segment depression or elevation 0.1 mV in at least
2 contiguous leads.
ACH Testing
Incremental doses of 2, 20, 100, and 200 g of ACH were manually
infused over a period of 3 minutes into the left coronary artery (LCA)
via the angiographic catheter. In patients who remained asymptom-
atic and showed no diagnostic ST-segment changes during LCA ACH
infusion, 80 g of ACH were injected into the right coronary artery
(RCA).
12
The ACH doses used in our protocol were derived from the
multicenter Evaluation of Nifedipine and Cerivastatin on Recovery of
Coronary Endothelial Function (ENCORE) study.
13
In this trial, the
dose for the left anterior descending artery and for the left circumex
artery was 100 g in each vessel injected via a selective catheter. For
practical reasons, the ACH injection in the present study was per-
formed unselectively via the diagnostic catheter in the LCA with a
maximum dose of 200 g.
Transient atrioventricular block was frequently observed, mostly
during provocation of the RCA. It almost always resolved within
seconds after reducing the speed of the manual injection. Therefore,
we did not test the RCA with a pacing catheter in the right ventri-
cle, avoiding potential complications. A bolus of glyceryl trinitrate
0.2 mg (Perlinganit, Schwarz Pharma, Monheim, Germany) was
injected into the LCA or RCA to relieve angina and severe epicardial
constriction. Nitrates were also infused routinely at the end of the
ACH test into the RCA and LCA.
ACH Test Assessment
Angiographic responses during the ACH test were analyzed by
using computerized quantitative coronary angiography (QCA-CMS,
Version 6.0, Medis-Software, Leiden, The Netherlands). The ACH
test was considered positive for epicardial coronary spasm in the pres-
ence of focal or diffuse epicardial coronary diameter reduction 75%
in comparison with the relaxed state following intracoronary nitro-
glycerine infusion in any epicardial coronary artery segment together
with the reproduction of the patients symptoms and ischemic ECG
shifts. Both the location and type of epicardial coronary spasm
(ie, focal versus diffuse) were also assessed.
14
Focal constriction was
dened as a circumscribed transient vessel narrowing within the bor-
ders of 1 isolated or 2 neighboring coronary segments as dened by
the American Heart Association. Diffuse constriction was diagnosed
when the vessel narrowing was observed in 2 adjacent coronary seg-
ments. Proximal spasm was dened as vasoconstriction occurring in
segments 1, 5, 6, or 11. Midvessel spasm was recorded when occur-
ring in segments 2, 3, or 7, whereas distal spasm was dened as that
occurring in segments 4, 8, 9, 10, 12, 13, 14, or 15.
Microvascular spasm was diagnosed when typical ischemic
ST-segment changes and angina developed in the absence of epi-
cardial coronary constriction 75% diameter reduction.
5
Patients
who experienced no angina, constriction, or ST-segment shifts were
considered to have a negative ACH-test response (normal coronary
vasoreactivity). The ACH test was judged inconclusive in patients
who only experienced angina without ECG changes. The same was
true for those who had ST-segment shifts without reproduction of
their symptoms. Finally, tests with angiographic vasospasm and
ST-segment shifts but no angina were also dened to be inconclusive.
Statistical Analysis
Data analysis was conducted with the use of SPSS 17.0 (SPSS Inc,
Chicago, IL). Results are expressed as meanstandard deviation. The
t test was used to compare continuous variables. The Fisher exact
test was used for categorical variables. Multiple logistic regression
analysis was performed by using forward variable selection based on
likelihood ratios to identify predictors for a pathological ACH test
and for identication of patients with epicardial spasm in compari-
son with those who have microvascular spasm. A 2-tailed P value of
<0.05 was considered signicant.
Results
Overall Results
The summary of the results of all patients is shown in Table 1.
In 74 of the 921 patients, the ACH test could not be performed
owing to logistic reasons or patient refusal. Among the remain-
ing 847 patients , the ACH test revealed epicardial coronary
spasm in 283 patients (33.4%), and microvascular spasm was
seen in another 205 (24.2%; Figures 1 and 2). In 117 patients,
the ACH test was negative (no symptoms, no ECG changes,
no epicardial spasm). In the remaining 242 patients, the test
was inconclusive because patients had reproduction of symp-
toms (n=87), ischemic ECG changes (n=81), and epicardial
spasm (n=74; 40 with associated ischemic ECG changes but
no reproduction of symptoms, 1 with reproduction of symp-
toms but without ECG shifts, and 33 with neither of the latter)
as the only abnormal nding, respectively.
Clinical Characteristics
Overall, patients with a positive ACH test were older, they
were more often female, and they more often presented with
by guest on May 1, 2014 http://circ.ahajournals.org/ Downloaded from
Ong et al ACH Test in Patients With Unobstructed Coronaries 1725
exertional chest pain. In addition, they more often had a pos-
itive family history for cardiovascular disease and they more
often showed a pathological response to noninvasive stress
testing. Interestingly, there were also fewer smokers in the
group with an abnormal ACH test than in the group with a
negative ACH test.
In comparison with patients with microvascular spasm,
those with epicardial spasm were more often male, were
smokers, and had a previous history of obstructive coronary
artery disease. They more often presented with resting chest
pain and a clinical presentation of acute coronary syndrome in
comparison with the microvascular spasm group. The detailed
results are shown in Table 2.
Multivariable analysis revealed that female sex, a previous
history of coronary artery disease, and a clinical presentation
with effort angina or mixed angina were independent predic-
tors for a pathological ACH-test response (Table 3). Moreover,
male sex, older age, cigarette smoking, a previous history of
coronary artery disease, resting angina, lower left ventricular
ejection fraction, and a clinical presentation with acute coro-
nary syndrome were identied as independent predictors for
epicardial spasm in comparison with patients with microvas-
cular spasm.
Angiographic Characteristics of Epicardial
Coronary Spasm
Epicardial coronary spasm occurred in 378 vessels in 282
patients, including 190 (67%) with 1-vessel spasm, 88 (31%)
with 2-vessel spasm, and 4 (1.4%) with 3-vessel spasm. The
most frequent type and location of spasm was distal and dif-
fuse (40%, P<0.01; Figures 2 and 3), mainly in segment 8
(distal left anterior descending artery). Only 9 patients (3.2%)
had a proximal and focal epicardial spasm. Patients with epi-
cardial plaques between 21% and 49% had epicardial spasm
more often (ie, 45%) than patients with only minor coronary
artery narrowings between 0% and 20% (ie, 30%, P<0.01).
However, spasm was found to be focally superimposed on
insignicant atherosclerotic lesions in only 13 cases (4.6%).
Table 1. Patient Characteristics All Patients
All Patients ACH Pathological ACH Negative P Value
847 488 (58) 359 (42)
Sex (male), n (%) 362 (43) 164 (34) 198 (55) <0.0005
Age, y, meanSD 61.811.6 62.811.1 60.512.1 0.006
Previous history of obstructive coronary artery disease 164 (19) 105 (22) 59 (16) 0.065
Admissions for chest pain before ACH test 242 (28.6) 136 (28) 106 (29.5) 0.64
Diagnostic angiography before ACH test 274 (32.3) 167 (34) 107 (29.8) 0.18
Noninvasive test for ischemia performed 565 (66.7) 340 (70) 225 (62.7) 0.039
Positive response to noninvasive test for ischemia 328 (38.7) 210 (43) 118 (32.9) 0.023
Clinical presentation
Predominantly resting chest pain 346 (41) 168 (34) 178 (50) <0.0005
Predominantly exertional chest pain 222 (26) 145 (30) 77 (21) 0.007
Effort and resting chest pain 238 (28) 154 (32) 84 (23) 0.011
Troponin-positive ACS 41 (5) 21 (4) 20 (6) 0.421
ACH test
LCA only 556 (65.6) 395 (81) 161 (45) <0.0005
RCA only 2 (0.02) 1 (0.2) 1 (0.3) 1.0
LCA+RCA 289 (34) 92 (19) 197 (55) <0.0005
LVEF %, meanSD 7211 7210 7111 0.31
Risk factors
Hypertension 609 (72) 346 (71) 263 (73) 0.49
Diabetes mellitus 142 (17) 84 (17.2) 58 (16) 0.71
Hypercholesterolemia 460 (54) 275 (56.3) 185 (52) 0.19
Smoking 307 (36) 161 (33) 146 (41) 0.025
Positive family history for CVD 441 (52) 271 (55.5) 170 (47.4) 0.022
Values shown are n (%), unless stated otherwise. ACH indicates acetylcholine; ACH test, intracoronary acetylcholine provocation testing; ACS
indicates acute coronary syndrome; CVD, cardiovascular disease; LCA, left coronary artery; LVEF, left ventricular ejection fraction; RCA, right coronary
artery; and SD, standard deviation.
Figure 1. Study ow chart. ACH test indicates intracoronary
acetylcholine provocation testing.
by guest on May 1, 2014 http://circ.ahajournals.org/ Downloaded from
1726 Circulation April 29, 2014
Complications
We did not observe any fatal or serious nonfatal compli-
cations (eg, sustained ventricular tachycardia, ventricular
brillation, or myocardial infarction due to prolonged
coronary spasm). However, 9 patients (1%) experienced
minor complications. One patient developed nonsustained
Table 2. Patient Characteristics According to ACH-Test Result
Epicardial Spasm Microvascular Spasm ACH Test Inconclusive ACH Test Normal P Value*
n= 283 (33.4) 205 (24.2) 242 (28.6) 117 (13.8)
Sex (male) 128 (45) 36 (18) 123 (51) 75 (64) <0.0005
Age, y, meanSD 6311 6211 6112 6012 0.025
Previous history of obstructive coronary artery disease 79 (28) 26 (13) 45 (19) 14 (12) <0.0005
Admissions for chest pain before ACH test 86 (30) 50 (24) 73 (30) 33 (28) 0.469
Diagnostic angiography before ACH test 105 (37) 62 (30) 75 (31) 32 (27) 0.188
Noninvasive test for ischemia performed 193 (68) 147 (72) 155 (64) 70 (60) 0.119
Positive response to noninvasive test for ischemia 118 (42) 92 (45) 84 (35) 34 (29) 0.103
Clinical presentation
Predominantly resting chest pain 112 (40) 56 (27) 111 (46) 67 (57) <0.0005
Predominantly exertional chest pain 72 (25) 73 (36) 55 (23) 22 (19) 0.003
Effort and resting chest pain 82 (29) 72 (35) 62 (26) 22 (19) 0.012
Troponin-positive ACS 17 (6) 4 (2) 14 (6) 6 (5) 0.128
ACH test
LCA only 240 (84.8) 155 (76) 126 (52) 35 (30) <0.0005
RCA only 1 (0.4) 0 1 (0.3) 0 1.0
LCA+RCA 42 (14.8) 50 (24) 115 (8) 82 (70) <0.0005
LVEF %, meanSD 7111 7410 7111 7211 0.010
Risk factors
Hypertension 192 (68) 154 (75) 175 (72) 88 (75) 0.271
Diabetes mellitus 50 (18) 34 (17) 41 (17) 17 (15) 0.912
Hypercholesterolemia 167 (59) 108 (53) 121 (50) 64 (55) 0.207
Smoking 113 (40) 48 (23) 108 (45) 38 (32) <0.0005
Positive family history for CVD 163 (58) 108 (53) 117 (48) 53 (45) 0.072
Values shown are n (%), unless stated otherwise. ACH indicates acetylcholine; ACH test, intracoronary acetylcholine provocation testing; ACS, acute coronary
syndrome; CVD, cardiovascular disease; LCA, left coronary artery; LVEF, left ventricular ejection fraction; RCA, right coronary artery; and SD, standard deviation.
*P refers to the comparison of all 4 patient groups.
Figure 2. A and B, LCA angiograms and
ECGs of a patient with epicardial spasm.
Note the diffuse but distally accentuated
narrowing of the LAD during acetylcholine
infusion (arrows) together with ischemic
ECG shifts (A) and resolution of both
ndings after nitroglycerine i.c. (B). C and
D, Example of a patient with microvascular
spasm. During ACH the patient had
reproduction of angina, ischemic ECG
changes, but no epicardial constriction
(C). After nitroglycerine i.c., chest pain and
ECG changes resolved (D). ACH indicates
acetylcholine; i.c., intracoronary; LAD, left
anterior descending artery; and LCA, left
coronary artery.
by guest on May 1, 2014 http://circ.ahajournals.org/ Downloaded from
Ong et al ACH Test in Patients With Unobstructed Coronaries 1727
ventricular tachycardia during ACH provocation and 1
patient had fast paroxysmal atrial brillation that resolved
spontaneously after discontinuing the injection. Six patients
developed symptomatic bradycardia and transient hypoten-
sion that resolved spontaneously after stopping the ACH
injection in 5 patients; in 1 patient, the intravenous injection
of atropine was necessary to stabilize heart rate and blood
pressure. The remaining patient had catheter-induced coro-
nary spasm of the proximal right coronary artery associated
with ST-segment elevation that resolved after removing the
catheter. Apart from that, no other catheter-induced spasms
were observed. Statistical comparison of patients with and
those without a complication did not reveal any signicant
differences (data not shown).
Discussion
This is the largest study to assess the safety of ACH test-
ing in white patients showing that the ACH test is a safe
method for the assessment of coronary vasomotor function
when performed with an appropriate protocol. Moreover,
we report a high frequency of coronary microvascular
spasm in a large contemporary cohort of white patients
with anginal symptoms and unobstructed coronary arter-
ies. In addition, we could show that epicardial coronary
spasm is most often diffuse and located in the distal parts
of the epicardial vessels, probably as a sign of concomitant
microvascular disease.
Clinical Characterization
Comparison of the clinical characteristics between patients
with and those without coronary spasm revealed that female
sex, a previous history of coronary artery disease, and a clini-
cal presentation with effort angina or mixed angina were inde-
pendent predictors for a pathological ACH-test response. In
contrast to expectations, resting angina, male sex, and ciga-
rette smoking were not identied as signicant predictors for
the entire group. However, these variables were identied as
predictors for epicardial spasm.
Our study extends previous data in so far that we also found
a previous history of coronary artery disease, a lower left
ventricular ejection fraction, and a clinical presentation with
acute coronary syndrome as independent predictors for the
observation of epicardial spasm in response to ACH testing.
Therefore the results of our study provide a comprehensive
clinical characterization of white patients with angina despite
unobstructed coronary arteries with a high likelihood for epi-
cardial spasm.
Microvascular spasm was also found to be frequent in
our patients. Interestingly, hypertension and diabetes mel-
litus were not found to be predictors of microvascular spasm,
although both conditions are well known to impair micro-
vascular function. However, diabetes mellitus was rather
infrequent in our cohort, and our data show that microvas-
cular disease is also common in patients without a history
of hypertension indicating that the feature hypertension
has a good sensitivity (ie, 80%), but it does not have a
high positive predictive value (ie, 70%) for the presence of
ACH-induced coronary spasm. Moreover, all cardiovascular
risk factors may have substantial and deleterious effects on
the microcirculation as recently reported by Granger et al.
15

The fact that epicardial spasm was often distal and diffuse
suggests that patients with microvascular spasm may also
experience distal epicardial spasm as previously shown in
smaller cohorts.
16,17
Larger studies are needed to elucidate
the relationship between epicardial and microvascular coro-
nary vasomotor disorders.
Angiographic Characteristics
The detailed analysis of the angiographic characteristics
of our patients revealed that diffuse and distal epicar-
dial coronary spasm was the most frequent finding. Our
results contrast with a report on white patients by Bertrand
et al
6
who most often found focal epicardial spasm in
their patients. This difference is most probably due to
Table 3. Multivariable Analysis
Pathological ACH test vs normal ACH test
Female sex 2.501; 1.8753.335; <0.0005
Previous history of coronary
artery disease
1.351; 1.0581.552; 0.023
Clinical presentation without
resting angina
1.749; 1.3142.330; <0.0005
Epicardial vs microvascular spasm
Male sex 1.679; 1.4911.798; <0.0005
Age 1.023; 1.0031.042; 0.022
Cigarette smoking 1.463; 1.1491.661; 0.008
Previous history of coronary artery disease 1.536; 1.2091.728; 0.005
Resting angina 1.518; 1.2611.685; 0.001
Clinical presentation with acute
coronary syndrome
1.749; 1.1921.922; 0.020
Left ventricular ejection fraction 0.979; 0.9600.998; 0.034
Values shown are odds ratio, condence interval, and P value. ACH indicates
acetylcholine; and ACH test, intracoronary acetylcholine provocation testing;
Figure 3. Graphic showing the distribution of type (diffuse,
focal, combination) and location (proximal, midsegment, distal,
combination) of epicardial coronary artery spasm (n=283).
The most frequent nding was a distal and diffuse spasm
(40%, P<0.01).
by guest on May 1, 2014 http://circ.ahajournals.org/ Downloaded from
1728 Circulation April 29, 2014
the different substance used for provocation of spasm
(ie, ergonovine in the study of Bertrand) and the different
route of administration (intravenous versus intracoronary).
A study by Goto et al
18
showed that coronary spasm can
often be elicited by ACH even if ergonovine did not reveal
any spasm. Moreover, our results are comparable to a more
recent study by Coma-Canella et al,
19
suggesting that distal
and diffuse spasm is a frequent observation in whites who
have angina and unobstructed coronary arteries. In addi-
tion, the prevalence of coronary spasm of 32.3% reported
in an Asian cohort of 685 Japanese patients appears to be
similar to our findings.
7
Recently, Sato et al
20
reported their ndings from 1877
patients who underwent ACH testing with the use of similar
criteria as in our study. They found a pathological ACH-test
response in 53% with 511 patients having focal spasm and
362 with diffuse spasm. Diffuse spasm was associated with
a better prognosis after 5 years in comparison with focal
spasm. In both studies, a positive family history for cardio-
vascular disease was more often found in patients with a
spastic ACH-test response, albeit in our study with a higher
frequency (ie, 55.5% in comparison with only 17% in the
study by Sato et al). Complication rates were similarly low
in both studies. The main difference in comparison with our
study is the inclusion of patients with an epicardial stenosis
>75%. This probably explains the high number of patients
with focal spasm (ie, 59% of all patients with spasm) in com-
parison with only 18% in our study. This is supported by
a study from Okumura et al
21
showing that diffuse spasm
is frequently found in patients without advanced organic
stenotic lesions. In addition, Saito et al
22
showed that the
presence of epicardial plaque is likely to be related to the
occurrence of focal spasm. It should, however, be noted that
there is currently no consensus denition for diffuse or focal
coronary spasm. Clearly, comparative studies between Asian
and white patients with stringent inclusion criteria and simi-
lar provocation test protocols should be performed to ulti-
mately answer the question of whether there are differences
in the prevalence and type of coronary spasm in ethnically
diverse groups.
Safety
Because of its invasive nature, there has been a lot of skepti-
cism regarding intracoronary provocation testing for coronary
spasm because of the potential complications associated with
the test. Interestingly, it is not the fact that coronary angiog-
raphy is required for performing the test that raises concern,
but the fear of irreversible spasm leading to arrhythmia and
death due to the provocative testing itself.
9
However, previous
studies in Asian, and white patients, as well, have demon-
strated that the test is reasonably safe. Bertrand et al,
6
using
intravenous ergonovine, had no serious irreversible complica-
tions among their 1088 patients, and Harding et al,
23
report-
ing some 3447 intracoronary ergonovine tests in American
patients, only had a single patient with serious complications
such as myocardial infarction or ventricular tachycardia/
brillation, corresponding to a complication rate of 0.03%.
A higher complication rate was reported by Sueda et al,
7
who
used intracoronary ACH in 685 patients and experienced
sustained ventricular tachycardia, shock, or cardiac tampon-
ade in 1.3% of patients. In addition, Wei et al
24
have recently
reported their experience with 293 US patients who under-
went coronary reactivity testing reporting a complication rate
of 0.7% for serious adverse events such as coronary artery
dissection (1 patient) and myocardial infarction (1 patient).
These complication rates are comparable to our rate of 1%.
Thus, there is compelling evidence that the ACH test using a
stepwise approach with increasing doses as reported in our
study is a safe procedure that can routinely be performed in
the catheterization laboratory. One has to view these com-
plication rates in context with current complication rates for
diagnostic coronary angiography, which are similar to those
reported for ACH testing.
25,26
Clinical Implications
The detection of abnormal coronary vasomotion in patients
with anginal symptoms but angiographically unobstructed
coronary arteries not only leads to the reassurance of the
patient that a cause for the symptoms is found, but also
enables the physician to initiate appropriate medical ther-
apy (ie, calcium channel blockers and nitrates)
27
aimed at
reducing morbidity and mortality.
28,29
This may also have
important implications on healthcare systems because most
health carerelated costs in patients with unobstructed
coronary arteries are due to recurrent or ongoing angina
pectoris.
30
Moreover, despite treatment with calcium chan-
nel blockers, patients with coronary spasm may experience
persistent or recurrent episodes of angina at follow-up,
31

underpinning the need for the development of new drugs
for treatment of vasospastic angina. This report should also
encourage interventionalists to add the ACH test to their
portfolio in the search of functional causes for angina in
patients with unobstructed coronary arteries.
32
In patients
presenting with symptoms other than angina pectoris
(eg, syncope or heart failure), ACH testing may also be
useful because these conditions can also be caused by
coronary spasm.
33,34
Limitations
Because we did not challenge the RCA when coronary spasm
was provoked in the LCA, the frequency of multivessel spasm
may be underestimated.
We used a slightly different denition for epicardial coro-
nary spasm than other investigators, especially from Asia
35

(ie, 75% in comparison with subtotal vasoconstriction
and a maximum dose of 200 g in comparison with 100 g
of ACH as in the Asian protocols). Thus, the frequency of
coronary spasm may be higher than with the use of other
denitions.
The ACH test was not performed in the early morning in
all patients. Because a circadian variation of coronary spasm
36

has been described, the frequency of spasm might have been
higher, if early morning examinations had been conducted
consistently.
Conclusions
Epicardial and microvascular coronary spasm are fre-
quently found in white patients with anginal symptoms and
by guest on May 1, 2014 http://circ.ahajournals.org/ Downloaded from
Ong et al ACH Test in Patients With Unobstructed Coronaries 1729
unobstructed coronary arteries. Epicardial spasm is most often
diffuse and located in the distal parts of the epicardial vessels.
The ACH test is a safe technique to assess coronary vasomo-
tor function.
Acknowledgments
We are grateful to nurses and technicians in the catheterization labo-
ratories and to all staff members of the Department of Cardiology,
Robert-Bosch-Krankenhaus, Stuttgart, Germany for their help and
support during the study.
Disclosures
None.
References
1. Prinzmetal M, Kennamer R, Merliss R, Wada T, Bor N. Angina pectoris.
I. A variant form of angina pectoris; preliminary report. Am J Med.
1959;27:375388.
2. Cheng TO, Bashour T, Kelser GA Jr, Weiss L, Bacos J. Variant angina of
Prinzmetal with normal coronary arteriograms. A variant of the variant.
Circulation. 1973;47:476485.
3. Maseri A, LAbbate A, Baroldi G, Chierchia S, Marzilli M, Ballestra AM,
Severi S, Parodi O, Biagini A, Distante A, Pesola A. Coronary vasospasm
as a possible cause of myocardial infarction. A conclusion derived from
the study of preinfarction angina. N Engl J Med. 1978;299:12711277.
4. Myerburg RJ, Kessler KM, Mallon SM, Cox MM, deMarchena E, Interian
A Jr, Castellanos A. Life-threatening ventricular arrhythmias in patients
with silent myocardial ischemia due to coronary-artery spasm. N Engl J
Med. 1992;326:14511455.
5. Mohri M, Koyanagi M, Egashira K, Tagawa H, Ichiki T, Shimokawa H,
Takeshita A. Angina pectoris caused by coronary microvascular spasm.
Lancet. 1998;351:11651169.
6. Bertrand ME, LaBlanche JM, Tilmant PY, Thieuleux FA, Delforge MR,
Carre AG, Asseman P, Berzin B, Libersa C, Laurent JM. Frequency of
provoked coronary arterial spasm in 1089 consecutive patients undergoing
coronary arteriography. Circulation. 1982;65:12991306.
7. Sueda S, Ochi N, Kawada H, Matsuda S, Hayashi Y, Tsuruoka T, Uraoka
T. Frequency of provoked coronary vasospasm in patients undergoing cor-
onary arteriography with spasm provocation test of acetylcholine. Am J
Cardiol. 1999;83:11861190.
8. Beltrame JF, Sasayama S, Maseri A. Racial heterogeneity in coronary
artery vasomotor reactivity: differences between Japanese and Caucasian
patients. J Am Coll Cardiol. 1999;33:14421152.
9. Stern S, Bayes de Luna A. Coronary artery spasm: a 2009 update.
Circulation. 2009;119:25312534.
10. Ong P, Athanasiadis A, Hill S, Vogelsberg H, Voehringer M, Sechtem U.
Coronary artery spasm as a frequent cause of acute coronary syndrome:
The CASPAR (Coronary Artery Spasm in Patients With Acute Coronary
Syndrome) Study. J Am Coll Cardiol. 2008;52:523527.
11. Lscher TF, Pieper M, Tendera M, Vrolix M, Rutsch W, van den Branden
F, Gil R, Bischoff KO, Haude M, Fischer D, Meinertz T, Mnzel T. A ran-
domized placebo-controlled study on the effect of nifedipine on coronary
endothelial function and plaque formation in patients with coronary artery
disease: the ENCORE II study. Eur Heart J. 2009;30:15901597.
12. Sueda S, Mineoi K, Kondo T, Yano K, Ochi T, Ochi N, Fukuda H, Kukita
H, Kawada H, Matsuda S, Uraoka T. Absence of induced spasm by intra-
coronary injection of 50 micrograms acetylcholine in the right coronary
artery: usefulness of 80 micrograms of acetylcholine as a spasm provoca-
tion test [in Japanese]. J Cardiol. 1998;32:155161.
13. ENCORE Investigators. Effect of nifedipine and cerivastatin on coronary
endothelial function in patients with coronary artery disease: the ENCORE
I Study (Evaluation of Nifedipine and Cerivastatin On Recovery of coro-
nary Endothelial function). Circulation. 2003;107:422428.
14. Austen WG, Edwards JE, Frye RL, Gensini GG, Gott VL, Grifth LS,
McGoon DC, Murphy ML, Roe BB. A reporting system on patients evalu-
ated for coronary artery disease. Report of the Ad Hoc Committee for
Grading of Coronary Artery Disease, Council on Cardiovascular Surgery,
American Heart Association. Circulation. 1975;51(4 suppl):540.
15. Granger DN, Rodrigues SF, Yildirim A, Senchenkova EY. Microvascular
responses to cardiovascular risk factors. Microcirculation. 2010;17:
192205.
16. Sun H, Mohri M, Shimokawa H, Usui M, Urakami L, Takeshita A.
Coronary microvascular spasm causes myocardial ischemia in patients
with vasospastic angina. J Am Coll Cardiol. 2002;39:847851.
17. Ong P, Athanasiadis A, Mahrholdt H, Borgulya G, Sechtem U, Kaski JC.
Increased coronary vasoconstrictor response to acetylcholine in women
with chest pain and normal coronary arteriograms (cardiac syndrome X).
Clin Res Cardiol. 2012;101:673681.
18. Goto A, Ito S, Kondo H, Nomura Y, Yasue N, Suzumura H, Takeda
Y, Tomimoto S, Yamada Y, Horio T, Suzuki S, Fukutomi T, Itoh M.
Evaluation of adjunctive intracoronary administration of acetylcholine
following intravenous infusion of ergonovine to provoke coronary artery
spasm. J Cardiol. 1999;34:309316.
19. Coma-Canella I, Castano S, Macas A, Calabuig J, Artaiz M. Ergonovine
test in angina with normal coronary arteries. Is it worth doing it? Int J
Cardiol. 2006;107:200206.
20. Sato K, Kaikita K, Nakayama N, Horio E, Yoshimura H, Ono T, Ohba
K, Tsujita K, Kojima S, Tayama S, Hokimoto S, Matsui K, Sugiyama S,
Yamabe H, Ogawa H. Coronary vasomotor response to intracoronary ace-
tylcholine injection, clinical features, and long-term prognosis in 873 con-
secutive patients with coronary spasm: analysis of a single-center study
over 20 years. J Am Heart Assoc. 2013;2:e000227.
21. Okumura K, Yasue H, Matsuyama K, Ogawa H, Kugiyama K, Ishizaka
H, Sumida H, Fujii H, Matsunaga T, Tsunoda R. Diffuse disorder of
coronary artery vasomotility in patients with coronary spastic angina.
Hyperreactivity to the constrictor effects of acetylcholine and the dilator
effects of nitroglycerin. J Am Coll Cardiol. 1996;27:4552.
22. Saito S, Yamagishi M, Takayama T, Chiku M, Koyama J, Ito K,
Higashikata T, Seguchi O, Honye J, Kanmatsuse K. Plaque morphology at
coronary sites with focal spasm in variant angina: study using intravascu-
lar ultrasound. Circ J. 2003;67:10411045.
23. Harding MB, Leithe ME, Mark DB, Nelson CL, Harrison JK, Hermiller
JB, Davidson CJ, Pryor DB, Bashore TM. Ergonovine maleate testing dur-
ing cardiac catheterization: a 10-year perspective in 3,447 patients without
signicant coronary artery disease or Prinzmetals variant angina. J Am
Coll Cardiol. 1992;20:107111.
24. Wei J, Mehta PK, Johnson BD, Samuels B, Kar S, Anderson RD, Azarbal
B, Petersen J, Sharaf B, Handberg E, Shufelt C, Kothawade K, Sopko G,
Lerman A, Shaw L, Kelsey SF, Pepine CJ, Merz CN. Safety of coronary
reactivity testing in women with no obstructive coronary artery disease:
results from the NHLBI-sponsored WISE (Womens Ischemia Syndrome
Evaluation) study. JACC Cardiovasc Interv. 2012;5:646653.
25. Chandrasekar B, Doucet S, Bilodeau L, Crepeau J, deGuise P, Gregoire J,
Gallo R, Cote G, Bonan R, Joyal M, Gosselin G, Tanguay JF, Dyrda I, Bois
M, Pasternac A. Complications of cardiac catheterization in the current era:
a single-center experience. Catheter Cardiovasc Interv. 2001;52:289295.
26. Noto TJ Jr, Johnson LW, Krone R, Weaver WF, Clark DA, Kramer JR Jr,
Vetrovec GW. Cardiac catheterization 1990: a report of the Registry of
the Society for Cardiac Angiography and Interventions (SCA&I). Cathet
Cardiovasc Diagn. 1991;24:7583.
27. Yilmaz A, Sechtem U. Angina pectoris in patients with normal coronary
angiograms: current pathophysiological concepts and therapeutic options.
Heart. 2012;98:10201029.
28. Johnson BD, Shaw LJ, Pepine CJ, Reis SE, Kelsey SF, Sopko G, Rogers
WJ, Mankad S, Sharaf BL, Bittner V, Bairey Merz CN. Persistent chest
pain predicts cardiovascular events in women without obstructive coronary
artery disease: results from the NIH-NHLBI-sponsored Womens Ischaemia
Syndrome Evaluation (WISE) study. Eur Heart J. 2006;27:14081415.
29. Ong P, Athanasiadis A, Borgulya G, Voehringer M, Sechtem U. 3-year
follow-up of patients with coronary artery spasm as cause of acute coronary
syndrome: the CASPAR (coronary artery spasm in patients with acute cor-
onary syndrome) study follow-up. J Am Coll Cardiol. 2011;57:147152.
30. Shaw LJ, Merz CN, Pepine CJ, Reis SE, Bittner V, Kip KE, Kelsey SF,
Olson M, Johnson BD, Mankad S, Sharaf BL, Rogers WJ, Pohost GM,
Sopko G; Womens Ischemia Syndrome Evaluation (WISE) Investigators.
The economic burden of angina in women with suspected ischemic heart
disease: results from the National Institutes of HealthNational Heart,
Lung, and Blood Institutesponsored Womens Ischemia Syndrome
Evaluation. Circulation. 2006;114:894904.
31. Bory M, Pierron F, Panagides D, Bonnet JL, Yvorra S, Desfossez L. Coronary
artery spasm in patients with normal or near normal coronary arteries. Long-
term follow-up of 277 patients. Eur Heart J. 1996;17:10151021.
32. Ong P, Athanasiadis A, Sechtem U. Patterns of coronary vasomotor responses
to intracoronary acetylcholine provocation. Heart. 2013;99:12881295.
33. Igarashi Y, Yamazoe M, Suzuki K, Tamura Y, Matsubara T, Tanabe
Y, Yamaguchi T, Watanabe K, Aizawa Y, Shibata A. Possible role of
by guest on May 1, 2014 http://circ.ahajournals.org/ Downloaded from
1730 Circulation April 29, 2014
coronary artery spasm in unexplained syncope. Am J Cardiol. 1990;65:
713717.
34. Inami T, Kataoka M, Shimura N, Ishiguro H, Kohshoh H, Taguchi H,
Yanagisawa R, Hara Y, Satoh T, Yoshino H. Left ventricular dysfunction
due to diffuse multiple vessel coronary artery spasm can be concealed in
dilated cardiomyopathy. Eur J Heart Fail. 2012;14:11301138.
35. JCS Joint Working Group. Guidelines for diagnosis and treatment of
patients with vasospastic angina (coronary spastic angina) (JCS 2008):
digest version. Circ J. 2010;74:17451762.
36. El-Tamimi H, Mansour M, Pepine CJ, Wargovich TJ, Chen H. Circadian
variation in coronary tone in patients with stable angina: Protective role of
the endothelium. Circulation. 1995;92:32013205.
CLINICAL PERSPECTIVE
Coronary spasm can cause myocardial ischemia and angina in patients with and those without obstructive coronary artery
disease. However, provocation tests using intracoronary acetylcholine provocation testing (ACH test) are rarely performed
in clinical routine in the United States and Europe. In this study, we assessed the clinical usefulness, angiographic character-
istics, and safety of the ACH test in white patients with unobstructed coronary arteries. Our study shows that the ACH test is
a safe method for the assessment of coronary vasomotor function and that patients with angina and angiographically unob-
structed coronary arteries often experience coronary spasm of the epicardial and microvascular coronary vessels. If such an
abnormality is diagnosed (eg, with intracoronary acetylcholine provocation testing), this not only leads to reassurance of the
patient that a cause for the symptoms is found, but also enables the physician to initiate the appropriate medical therapy (eg,
calcium channel blockers and nitrates aimed at reducing morbidity and mortality). Moreover, this may also have important
implications on our healthcare systems, because most health carerelated costs in patients with unobstructed coronary arter-
ies are due to recurrent or ongoing angina pectoris. However, consistent denitions for coronary vasomotor disorders are
needed to be able to compare the frequency of such disorders between different ethnic groups (eg, whites versus Asians). In
addition, based on the favorable safety prole of the ACH test as shown in this study, we hope to encourage interventional-
ists to add the ACH test to their portfolio in search of functional causes for angina, especially in patients with unobstructed
coronary arteries.
Go to http://cme.ahajournals.org to take the CME quiz for this article.
by guest on May 1, 2014 http://circ.ahajournals.org/ Downloaded from