Bortone A S, Hess O M, Eberli F R, Nonogi H, Marolf A P, Grimm J, Krayenbuehl H P
Medical Policlinic, Division of Cardiology, University Hospital, Zürich, Switzerland.
Circulation. 1989 Mar;79(3):516-27. doi: 10.1161/01.cir.79.3.516.
A reduced coronary flow reserve has been reported in patients with ischemialike symptoms and normal coronary arteries. In 13 such patients, both coronary vasomotion and flow reserve were studied. The luminal area of the proximal and distal third of the left anterior descending and left circumflex artery were determined by biplane quantitative coronary arteriography using a computer-assisted system. Patients were studied at rest, during submaximal supine bicycle exercise (4.0 minutes, 116 W), and 5 minutes after sublingual administration of 1.6 mg nitroglycerin. Heart rate, mean pulmonary pressure, and mean aortic pressure as well as the percent change of both proximal and distal luminal area were determined. In 10 of the 13 patients, coronary sinus blood flow was measured by coronary sinus thermodilution technique at rest and after dipyridamole infusion (0.5 mg/kg in 15 minutes) 10 +/- 5 days after quantitative coronary arteriography. Coronary flow ratio (dipyridamole/rest) and coronary resistance ratio (rest/dipyridamole) were determined in these patients. Patients were divided into two groups according to the behavior of the coronary vessels during exercise (vasodilation, group 1; vasoconstriction, group 2). Coronary vasodilation of the proximal (luminal area +26%, p less than 0.001) and distal (+45%, p less than 0.001) artery was observed in seven patients (group 1) during exercise and after sublingual nitroglycerin (+46%, p less than 0.001; and +99%, p less than 0.001, respectively). In group 2 (n = 6), however, there was coronary vasoconstriction of the distal vessel segments (-24%, p less than 0.001) during exercise, whereas the proximal coronary artery showed vasodilation (+26%, p less than 0.001) during exercise. After sublingual nitroglycerin, both vessel segments elicited vasodilation (distal coronary, +44%, p less than 0.001; proximal coronary artery, +47%, p less than 0.001). Coronary flow ratio amounted to 2.5 in group 1 and 1.2 in group 2 (p less than 0.05) and coronary resistance ratio to 2.7 in group 1 and to 1.2 in group 2 (p less than 0.05), respectively. Thus, among patients with ischemialike symptoms and normal coronary arteries, there is a group of patients (group 2) with an abnormal dilator response of the distal coronary arteries to the physiologic dilator stimulus of exercise and a reduced dilator capacity of the resistance vessels after dipyridamole (abnormal coronary vasodilator syndrome). The nature of this exercise-induced distal coronary vasoconstriction is not clear but might be due to an abnormal neurohumoral tone that may cause or contribute to the blunted vascular response during exercise.
据报道，有缺血样症状但冠状动脉正常的患者存在冠状动脉血流储备降低的情况。对13例此类患者的冠状动脉血管运动和血流储备进行了研究。使用计算机辅助系统，通过双平面定量冠状动脉造影术测定左前降支和左旋支动脉近端和远端三分之一处的管腔面积。在静息状态、次极量仰卧位自行车运动期间（4.0分钟，116瓦）以及舌下含服1.6毫克硝酸甘油后5分钟对患者进行研究。测定心率、平均肺动脉压、平均主动脉压以及近端和远端管腔面积的变化百分比。在13例患者中的10例中，在定量冠状动脉造影术后10±5天，通过冠状窦热稀释技术在静息状态和双嘧达莫输注后（15分钟内0.5毫克/千克）测量冠状窦血流量。测定这些患者的冠状动脉血流比（双嘧达莫/静息）和冠状动脉阻力比（静息/双嘧达莫）。根据运动期间冠状动脉血管的表现（血管扩张，第1组；血管收缩，第2组）将患者分为两组。在运动期间和舌下含服硝酸甘油后，7例患者（第1组）的近端（管腔面积增加26%，p<0.001）和远端（增加45%，p<0.001）动脉出现冠状动脉扩张（分别为增加46%，p<0.001；增加99%，p<0.001）。然而，在第2组（n=6）中，运动期间远端血管段出现冠状动脉收缩（-24%，p<0.001），而近端冠状动脉在运动期间出现扩张（增加26%，p<0.001）。舌下含服硝酸甘油后，两个血管段均出现扩张（远端冠状动脉，增加44%，p<0.001；近端冠状动脉，增加47%，p<0.001）。第1组的冠状动脉血流比为2.5，第2组为1.2（p<0.05），冠状动脉阻力比第1组为2.7，第2组为1.2（p<0.05）。因此，在有缺血样症状但冠状动脉正常的患者中，有一组患者（第2组）远端冠状动脉对运动的生理性扩张刺激的扩张反应异常，且双嘧达莫后阻力血管扩张能力降低（异常冠状动脉扩张综合征）。这种运动诱导的远端冠状动脉收缩的性质尚不清楚，但可能是由于异常的神经体液调节，这可能导致或促成运动期间血管反应减弱。
