Complications of Pharmacological Spasm Provocation Tests

As pharmacological spasm provocation tests, acetylcholine (ACh) [1-3] and ergonovine (ER) [4,5] are employed in the cardiac catheterization laboratory. However, we often encounter the major and minor complications during performing these procedures. As a diagnostic tool, we should perform spasm provocation tests more safely without major complications. Multiple and proximal spasm documented by the pharmacological agents may occur a hemodynamic instability, such as shock and hypotension. Moreover, irreversible arrhythmia may be recognized. Selective spasm provocation tests such as intracoronary injection of ACh and ER is safer than the intravenous injection of ER. The effect time of ACh is very short and we may have the spontaneous remission of the provoked spasm. Therefore, we can perform a selective right and left coronary artery testing separately. We already reported the major complications during ACh spasm provocation tests in 2000 [6]. Serious major complications were not different from the reports with an intravenous injection of ER. Recently, we employed the sequential spasm provocation tests to document coronary spasm in the clinic [7]. As sequential spasm provocation tests, we first perform intracoronary injection of ACh, second intracoronary administration of ER, and finally adding intracoronary injection of ACh just after ER test if we did not obtain the provoked spasm. However, the majority of cardiologists employed a single spasm provocation test for example ACh alone or ER only in each institution. Thus, they did not experience the difference of coronary artery response and complications between the two pharmacologic agents. We have been routinely used the ACh and/or ER spasm provocation tests to diagnose the presence of coronary artery spasm in the cardiac catheterization laboratory during a quarter century. In the Japanese Circulation Society guidelines, complications during invasive spasm provocation tests were not mentioned [8].