Korean J Radiol.  2019 May;20(5):719-728. 10.3348/kjr.2018.0847.

Coronary Computed Tomography Angiography for the Diagnosis of Vasospastic Angina: Comparison with Invasive Coronary Angiography and Ergonovine Provocation Test

• Park J
• Kim HK
• Park EA
• Park JB
• Lee SP
• Lee W
• Kim YJ
• Sohn DW

• KMID: 2442706
• DOI: http://doi.org/10.3348/kjr.2018.0847

Abstract

OBJECTIVE
To investigate the diagnostic validity of coronary computed tomography angiography (cCTA) in vasospastic angina (VA) and factors associated with discrepant results between invasive coronary angiography with the ergonovine provocation test (iCAG-EPT) and cCTA.
MATERIALS AND METHODS
Of the 1397 patients diagnosed with VA from 2006 to 2016, 33 patients (75 lesions) with available cCTA data from within 6 months before iCAG-EPT were included. The severity of spasm (% diameter stenosis [%DS]) on iCAG-EPT and cCTA was assessed, and the difference in %DS (Δ%DS) was calculated. Δ%DS was compared after classifying the lesions according to pre-cCTA-administered sublingual nitroglycerin (SL-NG) or beta-blockers. The lesions were further categorized with %DS ≥ 50% on iCAG-EPT or cCTA defined as a significant spasm, and the diagnostic performance of cCTA on identifying significant spasm relative to iCAG-EPT was assessed.
RESULTS
Compared to lesions without SL-NG treatment, those with SL-NG treatment showed a higher Δ%DS (39.2% vs. 22.1%, p = 0.002). However, there was no difference in Δ%DS with or without beta-blocker treatment (35.1% vs. 32.6%, p = 0.643). The significant difference in Δ%DS associated with SL-NG was more prominent in patients who were aged < 60 years, were male, had body mass index < 25 kg/m2, and had no history of hypertension, diabetes, or dyslipidemia. Based on iCAG-EPT as the reference, the per-lesion-based sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cCTA for VA diagnosis were 7.5%, 94.0%, 60.0%, 47.1%, and 48.0%, respectively.
CONCLUSION
For patients with clinically suspected VA, confirmation with iCAG-EPT needs to be considered without completely excluding the diagnosis of VA simply based on cCTA results, although further prospective studies are required for confirmation.

Keyword

Variant angina pectoris; Coronary computed tomography angiography; Coronary angiography; Provocation test; Nitroglycerin

MeSH Terms

Angina Pectoris, Variant
Angiography*
Body Mass Index
Constriction, Pathologic
Coronary Angiography*
Diagnosis*
Dyslipidemias
Ergonovine*
Humans
Hypertension
Male
Nitroglycerin
Prospective Studies
Sensitivity and Specificity
Spasm
Ergonovine
Nitroglycerin

Figure

• 

  Fig. 1 Flow diagram showing study design and patient selection.cCTA = coronary computed tomography angiography, EPT = ergonovine provocation test, iCAG = invasive coronary angiography, VA = vasospastic angina

• 

  Fig. 2 Effect of pre-medication on difference in detecting severity of spasm between cCTA and iCAG-EPT.A. SL-NG. B. BBs. BB = beta-blocker, iCAG-EPT = iCAG with EPT, SL-NG = sublingual nitroglycerine, %DS = % diameter stenosis, Δ%DS = difference in %DS

• 

  Fig. 3 Difference in severity of spasm between lesions according to time (from midnight to 10 AM or 10 AM to midnight) when cCTA was performed.

• 

  Fig. 4 Representative cases of Matched-Insignificant (A) and Matched-Significant (B) vasospasm between cCTA and iCAG-EPT.

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  Fig. 5 Concordance or discordance between cCTA and iCAG-EPT in differentiating significant from insignificant vasospasm with use of 50% cutoff value.

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