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1. Match the clinical features to the type of coronary artery spasm:

Features:
a.  Occurs in 1-5% of PTCA procedures and can usually be treated by intracoronary nitrates, calcium channel blockers, or repeat PTCA at low inflation pressure
b.  Rarely responds to nitrates
c.  Very common after PTCA and all percutaneous devices.

Spasm Type:
1. Spasm of the distal epicardial vessel (distal to the treatment site)
2. Intralesional spasm (at the treatment site)
3. Distal microvascular spasm

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Answer:  Coronary artery spasm at the target lesion has been reported in 1-5% of balloon angioplasty procedures. Risk factors include noncalcified lesions, possibly eccentric lesions and younger patients, but not variant angina. Intravascular ultrasound or angioscopy may be useful in cases where it is difficult to distinguish refractory spasm from severe recoil or dissection. Fortunately, most cases can be successfully treated by intracoronary vasodilators (nitrates and/or calcium blockers) with or without repeat PTCA at low inflation pressures. In contrast, spasm of the distal vessel is common after PTCA and virtually all percutaneous devices; repeat angiograms taken 15-30 minutes after balloon deflation demonstrate a 16-30% reduction in minimal lumen diameter and a 28% reduction in cross-sectional area. Treatment consists of nitrates (sublingual, intravenous, or intracoronary), nifedipine (sublingual), and/or diltiazem or verapamil (intravenous or intracoronary). In contrast to epicardial spasm, spasm of the distal microvascular bed rarely response to nitrates; the preferred treatment is intracoronary calcium antagonists. (Answer: a = 2; b = 3; c = 1).

2. The treatment site remains susceptible to spasm for several months after PTCA:

a. True
b. False

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Answer: The PTCA site remains susceptible to spasm for several months after the procedure. Ergonovine and acetylcholine can induce vasospasm after PTCA in 15% and 46% of patients, respectively. Spontaneous angina due to spasm may develop in the weeks or months following PTCA. (Answer: a)

3. Coronary artery spasm at the lesion site occurs least often after:

a. PTCA
b. Rotablator
c. TEC atherectomy
d. Excimer laser
e. Directional atherectomy

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Answer:  Compared to PTCA, coronary artery spasm after new devices occurs with equal or greater frequency. Spasm has been reported in 4 - 36% of Rotablator cases; in one study, severe spasm resulting in threatened or abrupt occlusion and requiring repeat PTCA or CABG occurred in 12/743 patients (1.6%). Spasm has been reported in 1.2 - 16% of ELCA procedures: Independent predictors include smoking (relative risk 2.1), no diabetes (relative risk 2.2), and stenosis severity # 90% (relative risk 1.6). Spasm has also been reported in 0.8 - 1.6% of DCA and 6.6% of holmium-laser cases. Most cases of coronary spasm following new devices respond to intracoronary and intravenous nitrates with or without repeat balloon dilatation. (Answer: a)

4. The usual dose of intracoronary nitroglycerin for the treatment of coronary artery spasm is:

a. 50-100 mcg repeated at 50 mcg increments as needed up to a total of 300 mcg
b. 100-300 mcg repeated as needed up to a total of 1-2 mg
c. 1-2 mg repeated as needed up to 5-10 mg
d.     None of the above

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Answer:  Coronary artery spasm usually resolves promptly after the administration of intracoronary nitroglycerin (100-300 mcg), but repeated doses may be necessary (up to 2 mg). (Answer: b)

5. If spasm occurs at the treatment site, the guidewire should be partially or completely removed:

a. True
b. False

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Answer:  If intralesional spasm is evident, the guidewire should remain across the lesion to maintain vascular access. If spasm occurs distal to the PTCA site, partial or complete removal of the guidewire may facilitate resolution of spasm. (Answer: b)

6. A temporary transvenous pacemaker should be inserted prior to the administration of intracoronary verapamil or diltiazem when used to treat coronary spasm, due to the risk AV block, bradycardia, and significant hypotension:

a. True
b. False

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Answer:  A temporary transvenous pacemaker should be readily available. However, since the risk of AV block, bradycardia and hypotension are low, prophylactic insertion is not routinely recommended. (Answer: b)

7. Doses of calcium channel blockers recommended to treat coronary artery spasm include:

a. Verapamil: 0.1-0.2 mg IC repeated every 1-5 min as needed up to a maximum of 1.0-1.5 mg
b. Verapamil: 0.1-0.2 mg IV repeated every 1-5 min as needed up to a maximum of 1.0-1.5 mg
c. Verapamil: 1-2 mg IC repeated every 1-5 min as needed up to a maximum of 10-15 mg
d. Diltiazem: 0.5-2.5 mg IV over 1 min up to 5-10 mg as needed
e. Diltiazem: 5-25 mg IC over 1 min up to 50-100 mg as needed

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Answer:  Intracoronary verapamil (100 mcg/min up to 1.0 - 1.5 mg) or intracoronary diltiazem (0.5-2.5 mg over 1 minute, to a total of 5-10 mg) may reverse coronary spasm refractory to intracoronary nitroglycerin. Intravenous calcium antagonists, however, do no reliably relieve coronary vasospasm. (Answer: a)

8. A prolonged low-pressure inflation using a balloon matched to the reference segment is often successful at treating intralesional spasm:

a. True
b. False

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Answer:  If intralesional spasm persists despite the use of nitrates, a prolonged (2-5 minute) low-pressure (1-4 atm.) inflation using a balloon matched to the reference segment is frequently successful at "breaking" the spasm. In fact, the vast majority of episodes of spasm respond to nitrates and repeat PTCA. (Answer: a)

9. Intracoronary stenting may successfully treat refractory spasm, and may be considered after other non-operative alternatives have failed:

a. True
b. False

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Answer:  Intracoronary stenting has been used successfully for refractory spasm, but should be reserved for situations in which all other nonoperative alternatives have failed. Most such cases of "refractory" spasm are probably dissections, which should respond to stenting. (Answer: a)

10. Emergency bypass surgery is rarely necessary to treat coronary artery spasm:

a. True
b. False

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Answer:  Emergency bypass surgery is rarely necessary but should be considered for refractory spasm when there is ongoing ischemia, the vessel is suitable for grafting, and all other approaches (including stenting) have been exhausted. (Answer: a)

11. Which of the following statements about PTCA of organic stenoses in patients with variant angina are true:

a. A high technical success rate can be achieved
b. Procedural complications occur more often in patients with variant angina
c. Restenosis rates exceed 70%

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Answer:  PTCA of organic stenosis in patients with variant angina is associated with a high technical success rate; procedural complications, including coronary artery spasm, are no more frequent than during PTCA for other lesions. Recurrent spasm and rest angina are not uncommon following PTCA. Pharmacologic therapy with high-dose nitrates and calcium channel antagonists may reduce their frequency and severity, but restenosis rates approach 50%. Many patients derive symptomatic benefit, although the impact on event-free survival (compared to medical therapy or CABG) has not been evaluated. (Answer: a)