Hyperventilation and cold-pressor stress echocardiography combined with automated functional imaging non-invasively detected vasospastic angina

Abstract

A 47-year-old male presented with chest discomfort while sleeping. The patient was suspected of having vasospastic angina (VSA) and underwent hyperventilation and cold-pressor stress echocardiography. No chest pain, ECG changes or decreased wall motion was found. However, automated function imaging (AFI) showed decreased peak systolic strain at the apex and postsystolic shortening at both the apex and inferior wall, which was not found before the test. The provocation test revealed 99% stenosis in the right coronary artery #2 at a dose of 50 μg acetylcholine and 90% stenosis in the left coronary artery #8 at a dose of 100 μg. The patient was thus diagnosed as having VSA. The present case demonstrates the usefulness of AFI combined with hyperventilation and cold-pressor stress echocardiography as a screening examination for VSA.

Figure 1

Longitudinal strain curves and bull's eye plots. The bull's eye plots were obtained from the peak systolic strain (top) and postsystolic strain index (PSI; bottom) before (left) and immediately after hyperventilation and cold-pressor stress test (right), respectively. The decreased peak systolic longitudinal strain and increased PSI immediately after the test were observed in the inferoseptal and apical left ventricular segments that corresponded well with the affected arteries.

Figure 2

Acetylcholine provocation test. Administration of 50 μg acetylcholine resulted in vasospasm in the right coronary artery #2 and administration of 100 μg acetylcholine resulted in vasospasm in the left coronary artery #8; the arrows indicate the vasospasm sites.