Background

Heterogeneity in diagnostic criteria and provocation protocols has posed challenges in understanding the safety of coronary provocation testing with intracoronary acetylcholine (ACh) for the contemporary diagnosis of epicardial and microvascular spasm.

Objectives

We examined the safety of testing and subgroup differences in procedural risks based on ethnicity, diagnostic criteria, and provocation protocols.

Methods

PubMed and Embase were searched in November 2021 to identify original articles reporting procedural complications associated with intracoronary ACh administration. The primary outcome was the pooled estimate of the incidence of major complications including death, myocardial infarction, ventricular tachycardia/fibrillation, and shock.

Results

A total of 16 studies with 12,585 patients were included in the meta-analysis. The overall pooled estimate of the incidence of major complications was 0.5% (95% CI: 0.0%-1.3%) without any reports of death. Exploratory subgroup analyses revealed that the pooled incidence of major complications was significantly higher in the studies that followed the contemporary diagnosis criteria for epicardial spasm defined as ≥90% diameter reduction (1.0%; 95% CI: 0.3%-2.0%) but significantly lower in Western populations (0.0%; 95% CI: 0.0%-0.45%). The rate of positive epicardial spasm and the incidence of major complications were similar between provocation protocols using the maximum ACh doses of 100 μg and 200 μg.

Conclusions

Intracoronary ACh administration for the contemporary diagnosis of epicardial and microvascular spasm is a safe procedure. Moreover, excellent safety records are observed in Western populations primarily presenting with myocardial ischemia and/or infarction with nonobstructive coronary arteries. This study will help standardize ACh testing to improve clinical diagnosis and ensure procedural safety.

中文翻译：

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冠状动脉内乙酰胆碱激发试验的安全性和对标准方案的影响

背景

诊断标准和激发协议的异质性对理解冠状动脉内乙酰胆碱 (ACh) 冠状动脉激发试验在当代诊断心外膜和微血管痉挛中的安全性提出了挑战。

目标

我们根据种族、诊断标准和激发协议检查了测试的安全性和程序风险的亚组差异。

方法

2021 年 11 月对 PubMed 和 Embase 进行了搜索，以找出报告与冠状动脉内 ACh 给药相关的手术并发症的原始文章。主要结果是对包括死亡、心肌梗死、室性心动过速/颤动和休克在内的主要并发症发生率的汇总估计。

结果

荟萃分析共纳入 16 项研究，共 12,585 名患者。主要并发症发生率的总体汇总估计为 0.5%（95% CI：0.0%-1.3%），没有任何死亡报告。探索性亚组分析显示，在遵循当代心外膜痉挛诊断标准（定义为直径减小≥90%）的研究中，主要并发症的合并发生率显着更高（1.0%；95% CI：0.3%-2.0%），但显着降低在西方人群中（0.0%；95% CI：0.0%-0.45%）。使用最大 ACh 剂量 100 μg 和 200 μg 的激发方案之间的心外膜痉挛阳性率和主要并发症的发生率相似。

结论

现代诊断心外膜和微血管痉挛的冠状动脉内 Ach 给药是一种安全的程序。此外，在主要表现为心肌缺血和/或非阻塞性冠状动脉梗塞的西方人群中观察到了出色的安全记录。这项研究将有助于标准化 ACh 检测，以改善临床诊断并确保程序安全。