JCS/CVIT/JCC 2023 guideline focused update on diagnosis and treatment of vasospastic angina (coronary spastic angina) and coronary microvascular dysfunction
2023; Elsevier BV; Volume: 82; Issue: 4 Linguagem: Inglês
10.1016/j.jjcc.2023.06.009
ISSN1876-4738
AutoresSeiji Hokimoto, Koichi Kaikita, Satoshi Yasuda, Kenichi Tsujita, Masaharu Ishihara, Tetsuya Matoba, Yasushi Matsuzawa, Yoshiaki Mitsutake, Yoshihide Mitani, Toyoaki Murohara, Takashi Noda, Koichi Node, Teruo Noguchi, Hiroshi Suzuki, Jun Takahashi, Yasuhiko Tanabe, Atsushi Tanaka, Nobuhiro Tanaka, Hiroki Teragawa, Takanori Yasu, Michihiro Yoshimura, Yasuhide Asaumi, Shigeo Godo, Hiroki Ikenaga, Takahiro Imanaka, Kohei Ishibashi, Masanobu Ishii, Takayuki Ishihara, Yunosuke Matsuura, Hiroyuki Miura, Yasuhiro Nakano, Takayuki Ogawa, Takashi Shiroto, Hirofumi Soejima, Ryu Takagi, Akihito Tanaka, Atsushi Tanaka, Akira Taruya, Etsuko Tsuda, Kohei Wakabayashi, Kensuke Yokoi, T Minamino, Yoshihisa Nakagawa, Shozo Sueda, Hiroaki Shimokawa, Hisao Ogawa,
Tópico(s)Acute Ischemic Stroke Management
ResumoIn 2008, the Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) [[1]JCS Joint Working Group Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2008): digest version.Circ J. 2010; 74: 1745-1762Crossref PubMed Scopus (231) Google Scholar] were developed by the Japanese Circulation Society, and the revised version was published in 2013 [[2]JCS Joint Working Group Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2013): digest version.Circ J. 2014; 78: 2779-2801Crossref PubMed Google Scholar]. Since then, new findings from various fields such as coronary microvascular dysfunction (CMD), biomarkers, imaging, physiological functions, and genes have accumulated. Furthermore, together with the spread of emergency coronary angiography (CAG) for acute coronary syndrome (ACS) and the development of diagnostic techniques using high-sensitive troponin, the new concepts of myocardial infarction with non-obstructive coronary arteries (MINOCA) and ischemia with non-obstructive coronary artery disease (INOCA) have been proposed [[3]Bairey Merz C.N. Pepine C.J. Walsh M.N. Fleg J.L. Ischemia and No Obstructive Coronary Artery Disease (INOCA): Developing evidence-based therapies and research agenda for the next decade.Circulation. 2017; 135: 1075-1092Crossref PubMed Scopus (438) Google Scholar,[4]Beltrame J.F. Assessing patients with myocardial infarction and nonobstructed coronary arteries (MINOCA).J Intern Med. 2013; 273: 182-185Crossref PubMed Scopus (87) Google Scholar]. The term “angina pectoris”, named in the mid-18th century, was extended to include variant forms [[5]Prinzmetal M. Kennamer R. Merliss R. Wada T. Bor N. Angina pectoris. I. A variant form of angina pectoris: preliminary report.Am J Med. 1959; 27: 375-388Abstract Full Text PDF PubMed Google Scholar] in the 20th century, and as a result of advances in both invasive and noninvasive diagnostic techniques and pharmaco- or catheter therapy, the European Society of Cardiology (ESC) proposed the concept of chronic coronary syndrome (CCS), taking into account the need for ongoing risk management in the 21st century [[6]Knuuti J. Wijns W. Saraste A. Capodanno D. Barbato E. Funck-Brentano C. et al.2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes: the task force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC).Eur Heart J. 2020; 41: 407-477Crossref PubMed Scopus (3299) Google Scholar]. Coronary spasm, for which regional and racial differences have been noted, is not rare in Europe and the USA [[7]Yasue H. Nakagawa H. Itoh T. Harada E. Mizuno Y. Coronary artery spasm: clinical features, diagnosis, pathogenesis, and treatment.J Cardiol. 2008; 51: 2-17Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar,[8]Pristipino C. Beltrame J.F. Finocchiaro M.L. Hattori R. Fujita M. Mongiardo R. et al.Major racial differences in coronary constrictor response between Japanese and Caucasians with recent myocardial infarction.Circulation. 2000; 101: 1102-1108Crossref PubMed Google Scholar]. The Coronary Vasomotion Disorders International Study (COVADIS) group, an international research group on coronary artery dysfunction, published criteria on vasospastic angina (VSA) in 2017 [[9]Beltrame J.F. Crea F. Kaski J.C. Ogawa H. Ong P. Sechtem U. et al.Coronary Vasomotion Disorders International Study Group (COVADIS). International standardization of diagnostic criteria for vasospastic angina.Eur Heart J. 2017; 38: 2565-2568PubMed Google Scholar], and microvascular angina (MVA) in 2018 [[10]Ong P. Camici P.G. Beltrame J.F. Crea F. Shimokawa H. Sechtem U. et al.Coronary Vasomotion Disorders International Study Group (COVADIS). International standardization of diagnostic criteria for microvascular angina.Int J Cardiol. 2018; 250: 16-20Abstract Full Text Full Text PDF PubMed Scopus (398) Google Scholar]. In the case of MINOCA or INOCA, the importance of recognizing and considering functional abnormalities in the absence of organic lesions and without seeking noncardiac causes of chest symptoms is challenged [11Ford T.J. Stanley B. Sidik N. Good R. Rocchiccioli P. McEntegart M. et al.1-year outcomes of angina management guided by invasive coronary function testing (CorMicA).JACC Cardiovasc Interv. 2020; 13: 33-45Crossref PubMed Scopus (115) Google Scholar, 12Reynolds H.R. Picard M.H. Spertus J.A. Peteiro J. Lopez Sendon J.L. Senior R. et al.Natural history of patients with ischemia and no obstructive coronary artery disease: the CIAO-ISCHEMIA Study.Circulation. 2021; 144: 1008-1023Crossref PubMed Scopus (0) Google Scholar, 13Seitz A. Feenstra R. Konst R.E. Martínez Pereyra V. Beck S. Beijk M. et al.Acetylcholine rechallenge: a first step toward tailored treatment in patients with coronary artery spasm.JACC Cardiovasc Interv. 2022; 15: 65-75Crossref PubMed Scopus (22) Google Scholar, 14Shimokawa H. Suda A. Takahashi J. Berry C. Camici P.G. Crea F. et al.Clinical characteristics and prognosis of patients with microvascular angina: an international and prospective cohort study by the Coronary Vasomotor Disorders International Study (COVADIS) Group.Eur Heart J. 2021; 42: 4592-4600Crossref PubMed Scopus (57) Google Scholar, 15Takahashi T. Samuels B.A. Li W. Parikh M.A. Wei J. Moses J.W. et al.Safety of provocative testing with intracoronary acetylcholine and implications for standard protocols.J Am Coll Cardiol. 2022; 79: 2367-2378Crossref PubMed Scopus (17) Google Scholar, 16Crea F. Montone R.A. Rinaldi R. Pathophysiology of coronary microvascular dysfunction.Circ J. 2022; 86: 1319-1328Crossref PubMed Scopus (0) Google Scholar]. This focused update is based on the Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (2013 revision) [[2]JCS Joint Working Group Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2013): digest version.Circ J. 2014; 78: 2779-2801Crossref PubMed Google Scholar], JCS 2018 Guideline on diagnosis and treatment of acute coronary syndrome [[17]JCS Joint Working Group JCS 2018 guideline on diagnosis and treatment of acute coronary syndrome.Circ J. 2019; 83: 1085-1196Google Scholar], and JCS 2018 Guideline on diagnosis of chronic coronary heart diseases [[18]JCS Working Group JCS 2018 guideline on diagnosis of chronic coronary heart diseases.Circ J. 2021; 85: 402-572Google Scholar], while considering the position of coronary spasm, CMD, coronary microvascular spasm (MVS), and non-obstructive coronary artery disease (CAD) in the field of ischemic heart disease (IHD). Updates on the following topics have been provided.1.MINOCA and INOCA are described as new disease concepts related to coronary spasm.2.New findings on the pathophysiology, diagnosis, and treatment of coronary spasm have been added since the 2013 revision.(1)For pathophysiology: aldehyde dehydrogenase 2 (ALDH2) gene polymorphism, coronary MVS, spasm after implantation of drug-eluting stents (DES), and pediatric diseases.(2)For diagnosis: a review of the criteria, intravascular imaging such as intravascular ultrasound (IVUS), optical coherence tomography (OCT), and angioscopy, imaging such as computed tomography-derived fractional flow reserve (FFRCT) and magnetic resonance imaging (MRI), physiologic examinations such as coronary flow reserve (CFR), and index of microcirculatory resistance (IMR), and endothelial function tests.(3)For treatment: pharmacotherapy, nonpharmacotherapy, and cardiovascular rehabilitation.3.The diagnostic criteria for diffuse coronary spasm as well as focal coronary spasm during coronary angiography (CAG) are added.4.The diagrams are designed to help the reader understand the relationship among epicardial coronary spasm, coronary MVS and MVA related to CMD (Fig. 4, Fig. 5). In this focused update, recommendations and levels of evidence are classified in accordance with the updated JCS statement, encompassing the estimated benefit in proportion to risk (Table 1, Table 2).Table 1Classes of recommendation.Class IThere is evidence and/or general agreement that a given procedure or treatment is effective and/or usefulClass IIaThere is a high probability of efficacy/usefulness based on evidence and opinionClass IIbEffectiveness/usefulness is not well established based on evidence and opinionClass III (No benefit)There is evidence and/or general agreement that the procedure or treatment is not effective and/or usefulClass III (Harm)There is evidence and/or general agreement that the procedure or treatment is harmful Open table in a new tab Table 2Levels of evidence.Level ADemonstrated by multiple randomized clinical trials and/or meta-analysesLevel BDemonstrated by a single randomized clinical trial or large nonrandomized studiesLevel CConsensus from expert opinion and/or small clinical trials (including retrospective studies and case series) Open table in a new tab This focused update version was developed with the participation of 8 academic societies: The Japanese Circulation Society, Japanese College of Cardiology, Japanese Association of Cardiovascular Intervention and Therapeutics, Japanese Society of Pediatric Cardiology and Cardiac Surgery, Japanese Heart Rhythm Society, The Japanese Association of Cardiac Rehabilitation, The Japanese Coronary Association, and Japanese Association of Cardioangioscopy. Please note that the basic information is as in the 2013 revised edition, and that this is a focused update. Cases of acute myocardial infarction (AMI) without acute coronary occlusion or obstructive CAD have been reported [[19]Gross H. Steinberg W.H. Myocardial infarction without significant lesions of coronary arteries.Arch Intern Med (Chic). 1939; 64: 249-267Crossref Google Scholar,[20]Miller R.D. Burchell H.B. Edwards J.E. Myocardial infarction with and without acute coronary occlusion: a pathologic study.AMA Arch Intern Med. 1951; 88: 597-604Crossref PubMed Scopus (0) Google Scholar], and in 2012, the term “MINOCA” was proposed to describe AMI without significant fixed stenosis (≥50%) in the epicardial coronary arteries on CAG [[4]Beltrame J.F. Assessing patients with myocardial infarction and nonobstructed coronary arteries (MINOCA).J Intern Med. 2013; 273: 182-185Crossref PubMed Scopus (87) Google Scholar]. It became widely accepted, together with the technical innovation of medical treatment for myocardial infarction (MI) with CAD (MI-CAD). The establishment of a measurement system for highly sensitive myocardial troponin, capable of detecting even minute myocardial injury, the proposal of a Universal Definition of AMI based on myocardial troponin variation [[21]Thygesen K. Alpert J.S. Jaffe A.S. Chaitman B.R. Bax J.J. Morrow D.A. et al.Fourth universal definition of myocardial infarction (2018).Circulation. 2018; 138: e618-e651Crossref PubMed Scopus (1426) Google Scholar], the availability of routine emergency CAG for AMI and the widespread use of reperfusion therapy for ST-elevation MI have improved the prognosis of AMI patients. On the other hand, there are a certain number of cases of MI “without obstructive coronary arteries”, and cardiologists have faced more than a few cases of difficulty in diagnosing and treating them, and the challenging problem has become apparent. The Fourth Universal Definition of Myocardial Infarction clearly stated that MI, which is based on acute myocardial ischemia such as atherosclerosis, thrombosis, or imbalance between oxygen demand and supply, is distinguished from myocardial injury, although both present an elevation of myocardial troponin above the 99th percentile of healthy individuals [[21]Thygesen K. Alpert J.S. Jaffe A.S. Chaitman B.R. Bax J.J. Morrow D.A. et al.Fourth universal definition of myocardial infarction (2018).Circulation. 2018; 138: e618-e651Crossref PubMed Scopus (1426) Google Scholar]. Therefore, in diagnosing MINOCA, it is necessary to exclude myocardial injury of noncardiac cause (e.g., sepsis or renal dysfunction) or myocardial injury from cardiac causes other than CAD (e.g., myocarditis or cardiomyopathy) that present similar symptoms to ACS. However, because MINOCA is a “working diagnosis”, tentatively diagnosed by the absence of significant stenosis at the time of CAG [22Pasupathy S. Tavella R. Beltrame J.F. The what, when, who, why, how and where of myocardial infarction with non-obstructive coronary arteries (MINOCA).Circ J. 2016; 80: 11-16Crossref PubMed Scopus (56) Google Scholar, 23Agewall S. Beltrame J.F. Reynolds H.R. Niessner A. Rosano G. Caforio A.L. et al.Working Group on Cardiovascular Pharmacotherapy. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries.Eur Heart J. 2017; 38: 143-153PubMed Google Scholar, 24Tamis-Holland J.E. Jneid H. Reynolds H.R. Agewall S. Brilakis E.S. Brown T.M. et al.Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association.Circulation. 2019; 139: e891-e908Crossref PubMed Scopus (443) Google Scholar], it is not always practical to exclude all myocardial injury due to nonischemic causes at the time of performing CAG. Thus, attention should be paid to whether MINOCA is being used as a “working diagnosis” or a final diagnosis. To avoid confusion, the term “troponin-positive non-obstructive coronary arteries” (TP-NOCA) has been proposed as a term for conditions presenting with elevated myocardial troponin, including myocardial injury of cardiac or noncardiac cause [[25]Pasupathy S. Tavella R. Beltrame J.F. Myocardial infarction with nonobstructive coronary arteries (MINOCA): the past, present, and future management.Circulation. 2017; 135: 1490-1493Crossref PubMed Scopus (124) Google Scholar] (Fig. 1). Importantly, MINOCA is considered as a “working diagnosis” at the time of CAG, as in the differential diagnosis of the cause of heart failure (HF), and differential diagnosis of the causes should be performed by using various modalities, as described in Chapter I.1.3. Potential causes of MINOCA are shown in Fig. 2 [[22]Pasupathy S. Tavella R. Beltrame J.F. The what, when, who, why, how and where of myocardial infarction with non-obstructive coronary arteries (MINOCA).Circ J. 2016; 80: 11-16Crossref PubMed Scopus (56) Google Scholar,[25]Pasupathy S. Tavella R. Beltrame J.F. Myocardial infarction with nonobstructive coronary arteries (MINOCA): the past, present, and future management.Circulation. 2017; 135: 1490-1493Crossref PubMed Scopus (124) Google Scholar]. Main causes due to CAD include plaque rupture/erosion, coronary artery spasm, CMD, coronary MVS, coronary artery dissection, and coronary artery embolism [[22]Pasupathy S. Tavella R. Beltrame J.F. The what, when, who, why, how and where of myocardial infarction with non-obstructive coronary arteries (MINOCA).Circ J. 2016; 80: 11-16Crossref PubMed Scopus (56) Google Scholar,24Tamis-Holland J.E. Jneid H. Reynolds H.R. Agewall S. Brilakis E.S. Brown T.M. et al.Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association.Circulation. 2019; 139: e891-e908Crossref PubMed Scopus (443) Google Scholar, 25Pasupathy S. Tavella R. Beltrame J.F. Myocardial infarction with nonobstructive coronary arteries (MINOCA): the past, present, and future management.Circulation. 2017; 135: 1490-1493Crossref PubMed Scopus (124) Google Scholar, 26Shibata T. Kawakami S. Noguchi T. Tanaka T. Asaumi Y. Kanaya T. et al.Prevalence, clinical features, and prognosis of acute myocardial infarction attributable to coronary artery embolism.Circulation. 2015; 132: 241-250Crossref PubMed Scopus (196) Google Scholar]. Main causes due to non-CAD include myocarditis, takotsubo syndrome, cardiomyopathy, congenital coagulation abnormalities, pulmonary thromboembolism, and sepsis. Initially, MINOCA is a “working diagnosis”, then non-coronary causes and differentiation of causes due to CAD, such as coronary spasm, are excluded. However, in daily practice, these might not be clearly distinguished and overlap with some other pathological conditions [[27]Lindahl B. Baron T. Albertucci M. Prati F. Myocardial infarction with non-obstructive coronary artery disease.EuroIntervention. 2021; 17: e875-e887Crossref PubMed Scopus (6) Google Scholar]. The etiology of coronary embolism, one of the causes of MINOCA, is mainly atrial fibrillation (AF), but septic emboli due to infective endocarditis or paradoxical embolism due to deep vein thrombosis may also occur [[26]Shibata T. Kawakami S. Noguchi T. Tanaka T. Asaumi Y. Kanaya T. et al.Prevalence, clinical features, and prognosis of acute myocardial infarction attributable to coronary artery embolism.Circulation. 2015; 132: 241-250Crossref PubMed Scopus (196) Google Scholar]. The possibility of concurrent non-CAD should be considered. In addition, it has been reported that in some cases are coronary spasm induced by pharmacological provocation testing in patients presenting with transient left ventricular dysfunction such as takotsubo syndrome [[28]Dote K. Sato H. Tateishi H. Uchida T. Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases. [in Japanese].J Cardiol. 1991; 21: 203-214PubMed Google Scholar,[29]Tsuchihashi K. Ueshima K. Uchida T. Oh-mura N. Kimura K. Owa M. et al.Angina Pectoris-Myocardial Infarction Investigations in Japan. Transient left ventricular apical ballooning without coronary artery stenosis: A novel heart syndrome mimicking acute myocardial infarction: Angina Pectoris-Myocardial Infarction Investigations in Japan.J Am Coll Cardiol. 2001; 38: 11-18Crossref PubMed Scopus (0) Google Scholar]. Therefore, in the clinical practice for MINOCA management, cardiologists and physicians should scrutinize for overlapping single or multiple etiologies and consider treatment according to the etiology. Coronary spasm involves hypercontraction based on a hyperactivity of the Rho-kinase pathway in vascular smooth muscle cells (VSMCs) [[30]Shimokawa H. Seto M. Katsumata N. Amano M. Kozai T. Yamawaki T. et al.Rho-kinase-mediated pathway induces enhanced myosin light chain phosphorylations in a swine model of coronary artery spasm.Cardiovasc Res. 1999; 43: 1029-1039Crossref PubMed Scopus (282) Google Scholar], endothelial dysfunction due to decreased production of nitric oxide (NO) by the vascular endothelium [[31]Kugiyama K. Yasue H. Okumura K. Ogawa H. Fujimoto K. Nakao K. et al.Nitric oxide activity is deficient in spasm arteries of patients with coronary spastic angina.Circulation. 1996; 94: 266-271Crossref PubMed Google Scholar], inflammation of the vascular adventitia and perivascular adipose tissue [[32]Ohyama K. Matsumoto Y. Takanami K. Ota H. Nishimiya K. Sugisawa J. et al.Coronary adventitial and perivascular adipose tissue inflammation in patients with vasospastic angina.J Am Coll Cardiol. 2018; 71: 414-425Crossref PubMed Scopus (116) Google Scholar], and increases in localized contraction of coronary arteries, resulting in decreased coronary blood flow and subsequent myocardial ischemia. Coronary spasm also leads to increases in coagulation [[33]Oshima S. Yasue H. Ogawa H. Okumura K. Matsuyama K. Fibrinopeptide A is released into the coronary circulation after coronary spasm.Circulation. 1990; 82: 2222-2225Crossref PubMed Scopus (66) Google Scholar], decreases in fibrinolytic activity [[34]Misumi I. Ogawa H. Masuda T. Sakamoto T. Okumura K. Yasue H. Increased plasma plasminogen activator inhibitor activity after coronary spasm.Int J Cardiol. 1993; 41: 21-29Abstract Full Text PDF PubMed Scopus (13) Google Scholar], and promotion of platelet activation and release of adhesion molecules [[35]Kaikita K. Ogawa H. Yasue H. Sakamoto T. Suefuji H. Sumida H. et al.Soluble P-selectin is released into the coronary circulation after coronary spasm.Circulation. 1995; 92: 1726-1730Crossref PubMed Scopus (88) Google Scholar], resulting in a thrombogenic state. A previous study using intravascular imaging investigated thrombus formation due to coronary spasm; the researchers observed the site of coronary spasm with OCT and found thrombus in 28% of coronary spasm sites or their proximal lesion, and plaque erosion with thrombus in 26% [[36]Shin E.S. Ann S.H. Singh G.B. Lim K.H. Yoon H.J. Hur S.H. et al.OCT-defined morphological characteristics of coronary artery spasm sites in vasospastic angina.JACC Cardiovasc Imaging. 2015; 8: 1059-1067Crossref PubMed Scopus (71) Google Scholar]. Another prospective observational study comparing OCT findings in vessels responsible for ACS due to coronary spasm and coronary spastic angina (CSA) reported that coronary spasm-induced ACS had more frequency of plaque erosion (69% vs. 27%), intimal tears (46% vs. 7%), and thrombus formation (28% vs. 5%) than CSA [[37]Park H.C. Shin J.H. Jeong W.K. Choi S.I. Kim S.G. Comparison of morphologic findings obtained by optical coherence tomography in acute coronary syndrome caused by vasospasm and chronic stable variant angina.Int J Cardiovasc Imaging. 2015; 31: 229-237Crossref PubMed Scopus (23) Google Scholar]. Based on these OCT studies and autopsy studies [[38]Lin C.S. Penha P.D. Zak F.G. Lin J.C. Morphodynamic interpretation of acute coronary thrombosis, with special reference to volcano-like eruption of atheromatous plaque caused by coronary artery spasm.Angiology. 1988; 39: 535-547Crossref PubMed Google Scholar], it is assumed that one of the mechanisms of vulnerable plaque rupture in ACS might be rupture of the fibrous capsule at the plaque surface and the protrusion of plaque contents into the vessel due to mechanical stress caused by coronary spasm, resulting in thrombus formation. In spontaneous coronary artery dissection (SCAD), another cause of MINOCA, the involvement of coronary spasm in the pathogenesis of coronary artery dissection has been reported [[39]Tsujita K. Miyazaki T. Kaikita K. Chitose T. Takaoka N. Soejima H. et al.Premenopausal woman with acute myocardial infarction caused by spontaneous coronary artery dissection and potential association with coronary vasospasm.Cardiovasc Interv Ther. 2012; 27: 121-126Crossref PubMed Scopus (6) Google Scholar,[40]Mori R. Macaya F. Escaned J. Mejía-Rentería H. Endothelial dysfunction and epicardial coronary spasm in a woman with previous spontaneous coronary artery dissection.JACC Cardiovasc Interv. 2020; 13: e219-e220Google Scholar]. On the other hand, a retrospective study comparing 10 patients with SCAD with a control group after performing an acetylcholine (ACh) provocation testing and measurement of CFR showed no involvement of coronary spasm or CMD in coronary artery dissection [[41]Waterbury T.M. Tweet M.S. Hayes S.N. Prasad A. Lerman A. Gulati R. Coronary endothelial function and spontaneous coronary artery dissection.Eur Heart J Acute Cardiovasc Care. 2020; 9: 90-95Crossref PubMed Google Scholar]. The association between coronary artery dissection and coronary spasm in MINOCA should be investigated in future large, prospective studies. Another single-center prospective observational study investigating the association between myocardial bridging, coronary spasm, and MINOCA reported that ACh-induced coronary spasm was a high risk for MINOCA in patients with myocardial bridge [[42]Montone R.A. Gurgoglione F.L. Del Buono M.G. Rinaldi R. Meucci M.C. Iannaccone G. et al.Interplay between myocardial bridging and coronary spasm in patients with myocardial ischemia and non-obstructive coronary arteries: pathogenic and prognostic implications.J Am Heart Assoc. 2021; 10e020535Crossref PubMed Scopus (35) Google Scholar], but not in patients without it, suggesting that myocardial bridge may be a cause of MINOCA and that coronary spasm may be involved in the pathogenesis of MINOCA due to myocardial bridge. We summarized previous reports from Japan and abroad regarding the epidemiology of coronary spasm and MINOCA [43Pasupathy S. Air T. Dreyer R.P. Tavella R. Beltrame J.F. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries.Circulation. 2015; 131: 861-870Crossref PubMed Google Scholar, 44Smilowitz N.R. Mahajan A.M. Roe M.T. Hellkamp A.S. Chiswell K. Gulati M. et al.Mortality of myocardial infarction by sex, age, and obstructive coronary artery disease status in the ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines).Circ Cardiovasc Qual Outcomes. 2017; 10e003443Crossref PubMed Scopus (194) Google Scholar, 45Lindahl B. Baron T. Erlinge D. Hadziosmanovic N. Nordenskjöld A. 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Characteristics and in-hospital mortality of patients with myocardial infarction in the absence of obstructive coronary artery disease in super-aging society.Int J Cardiol. 2020; 301: 108-113Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 52Pasupathy S. Lindahl B. Litwin P. Tavella R. Williams M.J.A. Air T. et al.Survival in patients with suspected myocardial infarction with nonobstructive coronary arteries: a comprehensive systematic review and meta-analysis from the MINOCA Global Collaboration.Circ Cardiovasc Qual Outcomes. 2021; 14e007880Crossref PubMed Scopus (26) Google Scholar, 53Sueda S. Sakaue T. Coronary artery spasm-induced acute myocardial infarction in patients with myocardial infarction with non-obstructive coronary arteries.Heart Vessels. 2021; 36: 1804-1810Google Scholar] (Table 3). The frequency of MINOCA in AMI ranged from approximately 3.5% to 11.1%, with no significant differences between reports, and the frequency of coronary spasm in MINOCA ranged from 3.7% to 72.6%, with a wide variation between reports. Because the frequency of provoked coronary spasm after AMI has been reported to be higher in Asians, including Japanese, than in Caucasians [[8]Pristipino C. Beltrame J.F. Finocchiaro M.L. Hattori R. Fujita M. Mongiardo R. et al.Major racial differences in coronary constrictor response between Japanese and Caucasians with recent myocardial infarction.Circulation. 2000; 101: 1102-1108Crossref PubMed Google Scholar,[54]Beltrame J.F. Sasayama S. Maseri A. Racial heterogeneity in coronary artery vasomotor reactivity: differences between Japanese and Caucasian patients.J Am Coll Cardiol. 1999; 33: 1442-1452Crossref PubMed Scopus (291) Google Scholar], racial differences may be a factor in the difference in the frequency of coronary spasm. On the other hand, the ACOVA study [[55]Ong P. Athanasiadis A. Borgulya G. Mahrholdt H. Kaski J.C. Sechtem U. High prevalence of a pathological response to acetylcholine testing in patients with stable angina pectoris and unobstructed coronary arteries: the ACOVA Study (Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries).J Am Coll Cardiol. 2012; 59: 655-662Crossref PubMed Scopus (301) Google Scholar] and an international study of Japanese and German patients reported that the frequency of ACh-induced coronary spasm was also high in Westerners [[56]Suda A. Seitz A. Odaka Y. Athanasiadis A. Pirozzolo G. Sato K. et al.Assessment of coronary vasomotor responses to acetylcholine in German and Japanese patients with epicardial coronary spasm: more similarities than differences?.Heart Vessels. 2021; 36: 337-344Crossref PubMed Scopus (0) Google Scholar]. Thus, there is a common understanding that there are no racial differences in the frequency of coronary spasm. The ESC and the American Heart Association have issued recommendations regarding the diagnostic protocol for MINOCA [[23]Agewall S. Beltrame J.F. Reynolds H.R. Niessner A. Rosano G. Caforio A.L. et al.Working Group on Cardiovascular Pharmacotherapy. ESC working group position paper on myocardial infarction with non-obstruc
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