冠状动脉内乙酰胆碱激发试验冠状动脉的血管收缩评估疾病
Summary
Intracoronary acetylcholine testing has been established for the assessment of epicardial coronary spasm more than 30 years ago. Recently, the focus has shifted towards the microcirculation and it has been shown that microvascular spasm can be detected using ACH-testing. This article describes the ACH-test and its implementation in daily routine.
Abstract
Intracoronary acetylcholine provocation testing (ACH-test) is an established method for assessment of epicardial coronary artery spasm in the catheterization laboratory which was introduced more than 30 years ago. Due to the short half-life of acetylcholine it can only be applied directly into the coronary arteries. Several studies have demonstrated the safety and clinical usefulness of this test. However, acetylcholine testing is only rarely applied in the U.S. or Europe. Nevertheless, it has been shown that 62% of Caucasian patients with stable angina and unobstructed coronary arteries on coronary angiography suffer from coronary vasomotor disorders that can be diagnosed with acetylcholine testing. In recent years it has been appreciated that the ACH-test not only assesses the presence of epicardial spasm but that it can also be useful for the detection of coronary microvascular spam. In such cases no epicardial spasm is seen after injection of acetylcholine but ischemic ECG shifts are present together with a reproduction of the patient’s symptoms during the test. This article describes the experience with the ACH-test and its implementation in daily clinical routine.
Introduction
心绞痛是冠状动脉疾病的标志和心外膜狭窄引起心肌缺血和运动诱导型心绞痛已多年建立的概念。然而，许多心绞痛患者没有被硝酸甘油或休息运动和救灾过程中的胸骨后疼痛，发作典型的黑社会。频繁的患者报告在休息或劳力和休息心绞痛的组合在劳累型心绞痛，以及呼吸急促作为可能的心绞痛当量。 1959年是变异型率先推出冠状动脉致使与心电图（ECG）ST段抬高相关休息心绞痛短暂痉挛的概念，但保留运动能力1。这一假设后来证实使用冠状动脉造影和它似乎冠状动脉痉挛可存在于患者的心外膜狭窄或正常冠状动脉2。在1980iES冠状动脉内乙酰胆碱激发试验（ACH测试）检测冠状动脉痉挛成立于日本，随后有兴趣的临床研究冠状动脉痉挛增加了3。
然而，在1977年引进的经皮冠状动脉介入，并于1986年第一次支架植入术后冠状动脉血管舒缩失调的利息至少在欧洲和美国的大幅度下降。这可能是也由于ACH-测试的侵入性（由于ACH的短半衰期它只能施用到冠状动脉冠状动脉痉挛的评估）。尽管如此，许多患者的症状和心肌缺血症状没有对冠状动脉造影4,5,6任何相关的心外膜狭窄。在这些患者冠状动脉内乙酰胆碱激发试验是非常有用的检测临床相关的冠状动脉血管舒缩障碍，并建立适当的药物治疗<sup> 7。
乙酰胆碱是在副交感神经系统的神经递质。它通过烟碱和毒蕈碱（mAchR的）受体的作用。后者是用于血管稳态的重要和乙酰胆碱上mAchR的结合作为非选择性激动剂。这些受体在内皮水平的活化导致一氧化氮介导的血管扩张，而在血管平滑肌细胞mAchR的活化导致血管收缩8。取决于内皮的完整性和平滑肌细胞的反应性冠状动脉内乙酰胆碱给药的净效应是血管舒张或血管收缩。冠状动脉响应于人类乙酰胆碱的生理反应尚不完全清楚，但据报道，由于示于正常的患者冠状动脉和血管舒张以及血管直径的高达25％的血管收缩可能是生理无心绞痛PEC托里斯9。
冠状动脉内乙酰胆碱激发试验已被建议的指导方针心脏病10欧洲社会以及为患者心绞痛和通畅的冠状动脉心外膜和/或微血管痉挛的评估日本流通协会指南11。冠状动脉内乙酰胆碱激发试验已经建立在日常临床常规我们在2003年机构的导管实验室自2006年以来的标准化协议一直跟着12。 ACH-测试通常是在所有患者的症状和心肌缺血症状的冠状动脉造影执行还没有相关的外膜狭窄（<50％）。 ACH-测试是根据下面描述的协议之后冠状动脉造影诊断立即执行。麦角]是用于痉挛激发试验与不同作用机制的另一个代理。详细在测试麦角新的信息可以在其他地方12被发现。
Protocol
Representative Results
Discussion
是可行的实现在日常临床常规的乙酰胆碱试验在导管实验室。除了ACH溶液的制备有一些必须解决之前开始测试，包括透亮心电图导联连续12导联心电图注册的几个技术问题。这是为了能够在测试过程中，以检测短暂性脑缺血的心电图改变是至关重要的。此外，重要的是要知道，ACH溶液只能用于2小时。之后，他们应该被重新制备。
它询问关于测试（已知或未知）期间发生的任?…
Divulgations
The authors have nothing to disclose.
Acknowledgements
This project is supported in part by grant KKF-15-1.
Materials
| Vial of 20 mg acetylcholine chloride powder and 1 Ampoule of 2 mL diluent | Bausch & Lomb | NDC 24 208-539-20 | |
| 3 x 100 ml NaCl 0.9 % | BBraun | 3200950 | |
| 3 x syringe 50 ml each | BBraun | 4187903 | |
| 1 x 2 ml syringe | BBraun | 4606027V | |
| 1 x 10 ml syringe | BBraun | 4606108V | |
| 2 x cannula 20 G 70mm | BBraun | 4665791 | |
| 5 x 5 ml syringe | BBraun | 4606051V | |
| Contrast agent Imeron 350 with a 10ml syringe for contrast injection | Bracco Imaging | 30699.03.00 | |
| Coronary angiography suite (AXIOM Artis MP eco ) | Siemens | n/a |
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