of medication with calcium channel blocker or nitrate compared with those in previous studies. Korean Circulation J 1999;293: KEY WORDSVariant

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1 Original Articles Korean Circulation J 1999;293: 급성심근경색증으로발현한변이형협심증환자의 임상적, 관동맥조영검사상특성및장기추적관찰 두영철 김재삼 채경수 송관욱 홍경순 박대균 한규록오동진 유규형 임종윤 고영박 이광학 이영 Clinical and Angiographic Characteristics and Long-term Follow-up in Patients with Variant Angina Who Presented as Acute Myocardial Infarction Young-Cheoul Doo, MD, Jae-Sam Kim, MD, Kyung-Soo Chae, MD, Kwan-Wook Song, MD, Kyung-Soon Hong, MD, Dae-Gyun Park, MD, Kyoo-Rok Han, MD, Dong-Jin Oh, MD, Kyu-Hyung Ryu, MD, Chong-Yun Rim, MD, Young-Bahk Koh, MD, Kwang-Hwahk Lee, MD and Yung Lee, MD Department of Internal Medicine, College of Medicine, Hallym University, Seoul, Korea ABSTRACT Background and ObjectivesThere were numerous reports for clinical characteristics and prognosis of patients with variant angina VA but little information is available for patients with VA who presented as acute myocardial infarction AMI. The purpose of this study is to determine the clinical and angiographic predictors for initial development of AMI in patients with VA and prognosis of patients with VA who presented as AMI. Materials and MethodsThe study group comprised 166 patients with VAforty one 25% of whom presented as AMI Group AMale 32, mean age 50 years and 125 presented as typical VA or unstable angina Group BMale 73, mean age 54 years. The diagnosis of VA was made by spontaneous spasm and ergonovine or acetylcholine only Group B provocation. Results1 Male gender 78% vs. 58%, p0.05, smoking 74% vs. 53%, p0.05, and disease duration 185 vs. 71 month, p0.0001, and ST-segment elevation during chest pain 71% vs. 23%, p0.05 were significantly higher in group A than in Group B. 2 Prevalence of fixed stenosis of 50% or greater was higher in Group A than in group B 12% vs. 2%, p0.05 and the percent stenosis after nitroglycerin injection was also greater in group A than in group B 435% vs. 282, p0.01, but the disease activity such as frequency of resting angina, spontaneous spasm, and multivessel spasm were not different between two groups. 3 During clinical follow-up at a mean duration of 2.7 years, three patient 2% in group B died of a cardiac cause. Non-fatal MI occurred 1 2% and 3 patients 2% in group A and B, respectively. ConclusionsOur data show that male gender, smoking, duration of disease, ST-segment elevation during chest pain, and a fixed stenosis of 50% or greater are predictors for initial development of AMI in patients with VA. The prognosis in group A is excellent and this may be associated with less severe atherosclerotic disease and a high rate 276

2 of medication with calcium channel blocker or nitrate compared with those in previous studies. Korean Circulation J 1999;293: KEY WORDSVariant angina Acute myocardial infarction Clinical and angiographic characteristics Prognosis. 서론 재료및방법 대상환자 방법 277

3 결과 임상적특성 278 Table 1. Clinical characteristics of subjects Group A Group B n41 patients n125 patients Sex MF* Age year Clinical manifestaton Variant anginaua 60 48%54 43% Rest pain 35 85% % Effort pain 6 15% 34 27% Pain related to alcohol 10 31% 39 32% Frequency of pain 5wk 5 12% 32 26% Risk factors Hypertension 6 15% 35 28% Diabetes mellitus 7 17% 34 27% Hyperlipidemia 7 17% 34 27% Smoking* 30 74% 66 53% Angina before admission 32 78% % Duration of disease month LV function EF, % EF40% 37 90% % AMI acute myocardial infarction LV Left ventricleefejection fractionuaunstable angina *p0.0 p0.01 p0.001 심전도및운동부하검사 Korean Circulation J 1999;293:

4 Table 2. ECG changes during chest pain and treadmill test of subjects Group A Group B n41 patients n125 patients ECG changes during chest pain ST-segment elevation* 29 71% 29 23% ST-segment depression 5 12% 13 10% T wave inversion % AV block 0 1 Ventricular tachycardia 1 1 No change 4 10% 13 10% Treadmill test premedication Positive on treadmill test 9 39% 22 30% ST-sement elevation 3 33% 0 ST-segment depression 6 67% % ECG electrocardiogram AMI acute myocardial infarctionavatrioventricular*p0.05 p0.001 관동맥조영검사및연축유발검사 추적관찰 : 심혈관계사건및자연관해율 Table 3. Angiographic characteristics and spasm provocation test of subjects Extents of CAD Group A Group B n41 patients n125 patients Normal 18 44% 74 59% Near normal 18 44% 48 38% Mild stenosis 50% & 70%* 5 12% 3 2% 1-vessel disease 6 15% 9 7% 2-vessel disease 0 1 Diameter stenosis of lesion % Before NTG injection After NTG Documentation of spasm Spontaneous coronary spasm 23 56% 56 45% Provocation test Ergonovine 18 44% 27 21% Acetylcholine 42 34% E1 or ach1 7 39% 36 52% Multivessel spasm 11 2% 24 19% Artery involved in spasm LADRCA Proximal AMIacute myocardial infarctioncadcoronary artery disease NTG nitroglycerin E1 or Ach1 ergonovine 50 ug or acetylcholine 20 ugladleft anterior descending artery RCA right coronary artery*p0.05 p

5 Table 4. Clinical follow-up of subjects Group A:Q파및비Q파심근경색증 280 Group A Group B n41 patients n125 patients Follow-up period year* Cardiac complications Death cardiac cause 0 3 2% Myocardial infarction 1 2% 3 2% Syncope 0 3 2% Medication Calcium channel blocker 36 88% % Nitrate 35 85% % Potassium channel 5 12% 26 21% ACE-inhibitor* 10 29% 9 7% Response to medication No sx without medication 3 7% 11 9% No sx with medication 25 61% 54 43% Sx without medication 2 5% 9 7% Sx with medication 11 27% 51 41% AMIacute myocardial infarctionsxsymptom No Sx without medicationspontaneous remission Sx with medicationrecurrent anginaaceangiotensin converting enzyme*p0.01 고 안 임상적특성 Korean Circulation J 1999;293:

6 Table 5. Clinical and angiographic characteristics and cardiac events of patients with variant angina who were presented with AMI by Q-wave infarction QMI n27 Group A non-qmi n14 Group B n125 Age year Sex Male 24 89%* 8 57% 73 58% Angina before admission 21 78% 12 86% % Frequency of pain 5wk 4 15% 1 7% 32 26% Duration of disease month Smoking 23 85% 7 50% 66 53% ECG changes during pain ST-segment elevation 24 89%* 5 36% 29 23% Extents of CAD Normal 12 44% 6 43% 74 59% Mild 50% & <70% 3 11% 2 14% 3 2% Diameter stenosis % After NTG injection ACE-inhibitor 9 33%* 1 7% 9 7% Cardiac complications Death cardiac cause % Myocardial infarction 0 1 7% 3 2% Remission 2 7% 1 7% 11 9% AMIacute myocardial infarctionqmiq wave myocardial infarctioncadcoronary artery disease ECGelectrocardiogramNTGnitroglycerinACEangiotensin converting enzyme*p0.01 vs. Group B p0.05 vs. non-qmi patients p0.05 vs. Group B p0.01 vs. non-qmi patients 관동맥조영검사및연축유발검사 281

7 추적관찰 282 Korean Circulation J 1999;293:

8 연구의제한점 요약 연구배경 : 방법 : 결과 : 283

9 결론 : 중심단어 REFERENCES 1) Hills LD, Braunwald E. Coronary artery spasm. N Engl J Med ) Conti CR, Curry RC. Coronary artery spasm and myocardial ischemia. Mod Concepts Cardiovasc Dis ) Maseri A, Chierchia S. Coronary artery spasm Demonstration, definition, diagnosis and consequences. Prog Cardiovasc Dis ) Maseri A, Davies G, Hackette D, Kaski SC. Coronary artery spasm and vasoconstriction The case for distinction. Circulation ) Vanhoutte PM, Shimokawa H. Endothelium-derived relaxing factor and coronary vasospasm. Circulation ) Yasue H, Matsuyama K, Okumura K, Morikami Y, Ogawa H. Responses of angiographically normal human coronary arteries to intracoronary injection of acetylcholine by age and segment. Circulation ) Miwa K, Goto M, Lee JD, Matsuyama F, Shimizu H, Kato T, et al. Supersensitivity of coronary arteries in variant angina to spasm induced by intracoronary acetylcholine. Am J Cardiol ) Okumura K, Yasue H, Horio Y, Takaoka K, Matsuyama K, Kugiyama K, et al. Multivessel coronary spasm in patients with variant angina A study with intracoronary injection of acetylcholine. Circulation ) Park YB, Lee YW. Coronary artery spasm in patients with coronary artery disease. Korean Circulation J ) Choi DJ, Koh KK, Kim HS, Kim CH, Oh BH, Park YB, et al. Acute myocardial infarction with normal coronary arteriography. Korean Circualtion J ) MacAlpin RN. Relation of coronary arterial spasm to sites of organic stenosis. Am J Cardiol ) Arnett EN, Roberts WC. Acute myocardial infarction and angiographically normal arteries An unproven combination. Circulation ) Severi S, Davies G, Maseri A, Mayullo P, L Abbate A. Long-term prognosis of variant angina with medical treatment. Am J Cardiol ) Waters DD, Szlachcic J, Miller DD, Theroux P. Clinical characteristics of patients with variant angina complicated by myocardial infarction or death within 1 month. Am J Cardiol ) Waters DD, Szlachcic J, Miller DD, et al. Factors influencing the lomg-term prognosis of treated patients with variant angina. Circulation ) Mark DB, Califf RM, Morris KG, et al. Clinical characteristics and long-term survival of patients with variant angina. Circulation ) Prinzmetal M, Kennamer R, Merliss R, Wada T, Bor N. A variant form of angina pectoris. Am J Med ) Swell WH. Coronary spasm as a cause of myocardial infarction. Angiology ) Vincent GM, Anderson JL, Marschall HW. Coronary spasm producing coronary thrombosis and myocardial infarction. N Engl J Med ) Park SJ, Park SW, Song JK, Kim JJ, Kim TW, Doo YC, et al. Clinical, angiographic characteristics and longterm follow-up in patients with variant angina. Korean Circulation J ) Kim CH, Ryu KH, Han SW, Park KY, Han YC, Hong KS, et al. Long-term follow-up in patients with vasospastic angina in relation to medication period and disease activity. Korean Journal of Medicine ) Kuller L, Perper J, Cooper M. Demographic characteristics and trends in arteriosclerotic heart disease mortality Sudden death and myocardial infarction. Circulation suppl ) Kannel WB. Update on the role of cigarette smoking in coronary artery disease. Am Heart J ) Jenkins CD, Rosenman RH, Zyzanski SJ. Cigarette smoking Its relationship to coronary heart disease and related risk factors in the Western Collaborative Group Study. Circulation ) Sugiishi M, Takatsu F. Cigarette smoking is a major risk factor for coronary spasm. Circulation ) Nakamura M, Takeshita A, Nose Y. Clinical characteristics associated with myocardial infarction, arrhythmias, and sudden death in patients with vasospastic angina. Circulation ) Walling A, Waters DD, Miller DD, Roy D, Pelletier GB, Theroux P. Long-term prognosis of patients with variant angina. Circulation ) Waters DD, Bouchard A, Theroux P. Spontaneous remission is a frequent outcome of variant angina. J Am Coll Cardiol ) Freeman SB, Richmond DR, Kelly DT. Long-term followup of verapamil and nitrate treatmnet of coronary spasm. Am J Cadiol ) Schick EC Jr, Liang C, Heupler FA Jr, et al. Randomized withdrawal from nifedipine Placebo-controlled study in patients with coronary artery spasm. Am Heart J ) Bott-Silverman C, Heupler FA Jr. Natural history of pure coronary artery spasm in patients treated medically. J Am Coll Cardiol Korean Circulation J 1999;293:

증례 Fig. 1. Computed tomography scan with contrast enhancement demonstrated intramural hematoma extending from aortic arch to thoracic descending aorta

증례 Fig. 1. Computed tomography scan with contrast enhancement demonstrated intramural hematoma extending from aortic arch to thoracic descending aorta Case Reports Korean Circulation J 2000;3011:1455-1459 대동맥벽내혈종환자에서베타차단제사용후 이형협심증에인한심근경색증 1 예 김중선 김병극 고영국 한승혁 서혜선 최동훈 조승연 A Case of Myocardial Infarction Caused by a Variant Angina during Treatment with