Rehan Rajan, Wong Christopher C Y, Weaver James, Jain Pankaj, Adams Mark, Ng Martin K C, Tremmel Jennifer A, Yong Andy S C
Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
Department of Cardiology, Concord Hospital, Sydney, New South Wales, Australia.
J Soc Cardiovasc Angiogr Interv. 2025 Jul 23;4(8):103668. doi: 10.1016/j.jscai.2025.103668. eCollection 2025 Aug.
Invasive coronary function testing, using acetylcholine (ACh) to diagnose coronary artery spasm (CAS) and coronary microvascular dysfunction assessment, is considered the gold standard for evaluating patients suffering from angina with nonobstructive coronary arteries. Notably, equipoise remains regarding the optimal sequence for coronary function testing, and no global consensus exists. Although nitroglycerin (NTG) is routinely administered post-radial access and prior to coronary microvascular dysfunction testing, its effect on subsequent ACh testing remains unclear. This study aimed to evaluate the diagnostic impact of preceding intravascular NTG on ACh provocation testing.
Multivessel ACh provocation testing was systematically performed in patients with suspected CAS. To assess the reinducibility of epicardial spasm, an ACh rechallenge was performed in patients who tested positive by readministering the spasm provocation dose into the affected coronary artery at different time intervals following the administration of intravascular NTG.
This multicenter study enrolled 102 patients (mean age 59.3 ± 10.0 years; 55% female), of whom 40 were diagnosed with epicardial CAS and underwent ACh rechallenge. Among these, 25 patients (62.5%) exhibited a diffuse spasm pattern, whereas 15 patients (37.5%) demonstrated focal spasm. After the ACh rechallenge, epicardial spasm was reinduced in 22 patients (55%), microvascular spasm in 6 patients (15%), and no spasm in 12 patients (30%). The sensitivity of ACh provocation testing declined to 55% at the end of the rechallenge.
Nitroglycerin administration reduces the diagnostic accuracy of ACh provocation testing for CAS in angina with nonobstructive coronary arteries patients. Findings from this study indicate that clinicians should avoid NTG administration prior to ACh testing or significantly delay ACh testing after NTG exposure to preserve diagnostic sensitivity.
侵入性冠状动脉功能测试，使用乙酰胆碱（ACh）诊断冠状动脉痉挛（CAS）以及评估冠状动脉微血管功能障碍，被认为是评估非阻塞性冠状动脉性心绞痛患者的金标准。值得注意的是，关于冠状动脉功能测试的最佳顺序仍存在平衡问题，尚未达成全球共识。尽管硝酸甘油（NTG）在桡动脉穿刺后和冠状动脉微血管功能障碍测试前常规使用，但其对随后的ACh测试的影响仍不清楚。本研究旨在评估血管内NTG预处理对ACh激发试验的诊断影响。
对疑似CAS的患者系统地进行多支血管ACh激发试验。为评估心外膜痉挛的再诱导性，对在血管内NTG给药后的不同时间间隔，通过向受影响的冠状动脉重新给予痉挛激发剂量而检测呈阳性的患者进行ACh再激发试验。
这项多中心研究纳入了102例患者（平均年龄59.3±10.0岁；55%为女性），其中40例被诊断为心外膜CAS并接受了ACh再激发试验。在这些患者中，25例（62.5%）表现为弥漫性痉挛模式，而15例（37.5%）表现为局灶性痉挛。ACh再激发试验后，22例患者（55%）再次诱发心外膜痉挛，6例患者（15%）诱发微血管痉挛，12例患者（30%）未出现痉挛。再激发试验结束时，ACh激发试验的敏感性降至55%。
硝酸甘油给药降低了非阻塞性冠状动脉性心绞痛患者中ACh激发试验对CAS的诊断准确性。本研究结果表明，临床医生应避免在ACh测试前使用NTG，或在接触NTG后显著延迟ACh测试，以保持诊断敏感性。
