Kuji Hiroki, Saito Yuichi, Kuranaga Shota, Nishi Takeshi, Tateishi Kazuya, Kato Ken, Kitahara Hideki, Kobayashi Yoshio
Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan.
Division of Cardiology, Chiba Cerebral and Cardiovascular Center, Japan.
Intern Med. 2025 Sep 4. doi: 10.2169/internalmedicine.5954-25.
Objective The intracoronary acetylcholine (ACh) provocation test is an invasive standard for diagnosing coronary spastic angina (CSA)/vasospastic angina. Although the guidelines recommend incremental doses of ACh, the clinical relevance of the significant response to lower ACh doses is unclear. Methods From April 2012 to June 2024, 636 patients with no significant epicardial coronary disease undergoing intracoronary ACh provocation testing for the diagnosis of CSA were included. Patients with positive ACh test results were divided into two groups: the low-dose positive group, defined as those who tested positive at the initial dose of ACh in the left and/or right coronary arteries without further dose escalation, and the high-dose positive group, including those who required higher doses for a positive result. The occurrence of intraprocedural adverse events and long-term outcomes was also evaluated. Results Of the 636 patients, 306 (48.1%) were classified as negative, 304 (47.8%) as high-dose positive, and 26 (4.1%) as low-dose positive based on the ACh provocation tests. The baseline characteristics did not differ significantly between the high- and low-dose positive groups. ST-segment elevation on electrocardiography during ACh tests and unstable angina during the follow-up period were more frequent in the low-dose positive group than in the high-dose positive group, while the overall clinical outcomes were similar among the groups. Conclusion Among patients with CSA diagnosed using ACh provocation testing, nearly 10% had a positive diagnosis at a low dose. There may be distinct underlying mechanisms and clinical outcomes depending on the ACh dose required for a positive test result.
目的 冠状动脉内乙酰胆碱（ACh）激发试验是诊断冠状动脉痉挛性心绞痛（CSA）/血管痉挛性心绞痛的侵入性标准。尽管指南推荐递增剂量的ACh，但较低剂量ACh产生显著反应的临床意义尚不清楚。方法 纳入2012年4月至2024年6月期间636例无明显心外膜冠状动脉疾病且接受冠状动脉内ACh激发试验以诊断CSA的患者。ACh试验结果阳性的患者分为两组：低剂量阳性组，定义为在左和/或右冠状动脉初始剂量ACh时检测呈阳性且无需进一步增加剂量的患者；高剂量阳性组，包括那些需要更高剂量才能获得阳性结果的患者。还评估了术中不良事件的发生情况和长期预后。结果 根据ACh激发试验，636例患者中，306例（48.1%）分类为阴性，304例（47.8%）为高剂量阳性，26例（4.1%）为低剂量阳性。高剂量和低剂量阳性组之间的基线特征无显著差异。低剂量阳性组在ACh试验期间心电图ST段抬高和随访期间不稳定型心绞痛的发生率高于高剂量阳性组，而各组间总体临床结局相似。结论 在使用ACh激发试验诊断的CSA患者中，近10%在低剂量时诊断为阳性。根据试验结果呈阳性所需的ACh剂量，可能存在不同的潜在机制和临床结局。
