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Images in Cardiovascular CT

Coronary vasospasm during CT angiography

Takehiro Nakahara MD, PhDa,*, Takuji Toyama MDb,Yoshito Tsushima MD, PhDc, Masahiko Kurabayashi MD, PhDa

aDepartment of Medicine and Biological Science, Gunma University Graduate School of Medicine, 3-39-22 Showa,

Maebashi, Gunma 371-8511, JapanbDepartment of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, JapancDepartment of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine,

Maebashi, Gunma, Japan

a r t i c l e i n f o

Article history:

Received 12 May 2014

Received in revised form

31 May 2014

Accepted 8 June 2014

Available online 17 June 2014

Keywords:

Cardiac CT

Routine use

Beta-blockers

Asian patients

Vasospastic angina

Landiolol

Conflicts of interest: The authors report no* Corresponding author.E-mail address: takehironakahara@gmail

1934-5925/$ e see front matter ª 2014 Sociehttp://dx.doi.org/10.1016/j.jcct.2014.06.005

a b s t r a c t

A 71-year-old man, a heavy smoker, was admitted for evaluation of “chest oppression”

after every dinner. Cardiac CT with a beta-blocker showed coronary stenosis in the left

circumflex. Although adenosine triphosphateestress perfusion single-photon emission CT

revealed no ischemia, Holter electrocardiography belatedly indicated an ST elevation

associated with his symptoms while smoking. He was diagnosed to have vasospastic

angina. Cardiac CT without a beta-blocker showed thin diffuse plaque and negative

remolding without any significant stenosis at the same site. Asian patients have a ten-

dency to develop vasospastic angina. Although beta-blockers are recommended for cardiac

CT, the routine administration of beta-blockers in cardiac CT may have some risk for

such cases.

ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved.

A 71-year-old man, who had been a heavy smoker (100 ciga-

rettes per day) for 50 years, was admitted for evaluation of

“chest oppression” after every dinner. He underwent Holter

electrocardiography and cardiac CT to evaluate atypical chest

pain with an intermediate risk.1 The dual-source CT (Soma-

tom Definition Flash; Siemens, Forchheim, Germany) with a

very-shorteacting beta-blocker (landiolol; Tmax, 3.7 minutes;

T1/2, 5 minutes) and sublingual nitroglycerin showed coro-

nary stenosis in the left circumflex (Fig. 1AeC). His blood

conflicts of interest.

.com (T. Nakahara).ty of Cardiovascular Com

pressure temporarily decreased to 95/46 mm Hg during the

test; however, it recovered to 110/54 mm Hg within a few

minutes. He reduced smoking to 30 cigarettes per day and

thereafter noticed “chest oppression” around 9 PM while

smoking. Holter electrocardiography belatedly indicated an

ST elevation associated with his symptoms while smoking

(Fig. 2), and adenosine triphosphateestress perfusion single-

photon emission CT revealed no ischemia. He was diag-

nosed to have vasospastic angina.2 He refused catheter

puted Tomography. All rights reserved.

Fig. 1 e (AeC) The result of cardiac CT with a beta-blocker. (A) Angiographic view (AG view), (B) curved multiplanar

reformation (CPR), (C) stretched CPR. These panels showed regional significant coronary stenosis in the left circumflex (LCx)

(arrows). (DeF) The result of cardiac CT without a beta-blocker. (D) Angiographic view, (E) curved CPR, (F) stretched CPR.

These panels showed thin diffuse plaque and negative remodeling without any significant stenosis at the same region

(striped arrows).

J o u rn a l o f C a r d i o v a s c u l a r C om p u t e d T omog r a p h y 8 ( 2 0 1 4 ) 3 2 8e3 3 0 329

angiography and stopped smoking, and his symptoms

completely disappeared with medication. Cardiac CT without

a beta-blocker showed thin diffuse plaque and negative

remolding without any significant stenosis at the same site

(Fig. 1DeF). Because beta-blockers can worsen vasospasm,

one of the possible explanations was that his vasospasm

during the first examination may have been provoked by the

Fig. 2 e Holter electrocardiography showed ST elev

beta-blocker. However, he did not show any critical problems,

because landiolol’s effect subsides immediately.

Asian patients have a tendency to develop vasospastic

angina.3 Although beta-blockers are recommended for cardiac

CT to optimize the image quality,4 the routine administration

of beta-blockers in cardiac CT may have some risk for such

cases.

ation (arrows) with symptom while smoking.

J o u r n a l o f C a r d i o v a s c u l a r C om p u t e d T omog r a p h y 8 ( 2 0 1 4 ) 3 2 8e3 3 0330

r e f e r e n c e s

1. Taylor AJ, Cerqueira M, Hodgson JM, et al; American College ofCardiology Foundation Appropriate Use Criteria Task Force;Society of Cardiovascular Computed Tomography; AmericanCollege of Radiology; American Heart Association; AmericanSociety of Echocardiography; American Society of NuclearCardiology; North American Society for CardiovascularImaging; Society for Cardiovascular Angiography andInterventions; Society for Cardiovascular Magnetic Resonance.ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010appropriate use criteria for cardiac computed tomography.A report of the American College of Cardiology FoundationAppropriate Use Criteria Task Force, the Society ofCardiovascular Computed Tomography, the American Collegeof Radiology, the American Heart Association, the American

Society of Echocardiography, the American Society of NuclearCardiology, the North American Society for CardiovascularImaging, the Society for Cardiovascular Angiography andInterventions, and the Society for Cardiovascular MagneticResonance. J Cardiovasc Comput Tomogr.2010;4(6):407.e1e407.e33.

2. JCS Joint Working Group. Guidelines for diagnosis andtreatment of patients with vasospastic angina (coronaryspastic angina) (JCS 2008): digest version. Circ J.2010;74:1745e1762.

3. Sasayama S. Heart disease in Asia. Circulation.2008;118:2669e2671.

4. Abbara S, Arbab-Zadeh A, Callister TQ, et al. SCCT guidelinesfor performance of coronary computed tomographicangiography: a report of the Society of CardiovascularComputed Tomography Guidelines Committee. J CardiovascComput Tomogr. 2009;3(3):190e204.