检测乙酰胆碱，然后使用腺苷进行冠状动脉血管舒缩疾病的侵入性诊断
Summary
冠状动脉血管舒动障碍是冠状动脉畅通阻患者心绞痛的常见功能原因。这些患者心绞痛（内型）的潜在机制可以通过基于乙酰胆碱激发试验的综合侵入性诊断程序来确定，然后对冠状动脉血流储备和微血管阻力进行多普勒衍生评估。
Abstract
超过50%接受冠状动脉造影的心肌缺血体征和症状患者冠状动脉畅通无阻。冠状动脉血管舒缩疾病（血管舒张受损和/或血管收缩/痉挛增强）是此类临床表现的重要功能原因。虽然血管舒张受损可以用正电子发射断层扫描或心脏磁共振成像等非侵入性技术进行评估，但目前尚无可靠的非侵入性技术来诊断冠状动脉痉挛症。因此，已经开发了用于诊断冠状动脉血管舒缩疾病的侵入性诊断程序（IDP），包括痉挛测试以及冠状动脉血管扩张的评估。识别潜在的疾病类型（所谓的内型）允许开始有针对性的药物治疗。尽管目前欧洲心脏病学会基于CorMicA研究的慢性冠脉综合征管理指南推荐了这种方法，但结果的可比性以及多中心试验目前受到冠状动脉功能检测机构方案的主要差异的阻碍。本文介绍了一种全面的 IDP 方案，包括用于诊断心上膜/微血管痉挛的冠状动脉内乙酰胆碱激发试验，然后进行基于多普勒线的冠状动脉血流储备 （CFR） 和充血微血管阻力 （HMR） 评估，以寻找冠状动脉血管舒张损伤。
Introduction
近年来，介入心脏病学在各个领域取得了实质性进展。这不仅包括使用经导管主动脉瓣置换术对心脏瓣膜进行介入治疗和二尖瓣和三尖瓣的边缘到边缘修复，还包括冠状动脉介入治疗1，2，3，4，5，6。后者包括使用旋转和冲击波疗法治疗慢性完全闭塞以及钙化病变的技术的进步。除了这些相当结构性的冠状动脉介入手术外，侵入性诊断程序（IDP）现已建立，以寻找功能性冠状动脉疾病（即冠状动脉痉挛和微血管功能障碍）7。后者包括一组异质性疾病，通常但不仅限于心绞痛和冠状动脉畅通的患者。这些血管舒缩疾病的主要机制是冠状动脉血管扩张受损、血管收缩/痉挛增强以及冠状动脉微血管抵抗增强。后者通常是由于阻塞性微血管疾病8。在解剖学上，冠状动脉血管舒缩症可能发生在心外膜动脉、冠状动脉微循环或两者兼而有之。冠状动脉血管舒缩障碍国际研究小组 （COVADIS） 发布了这些疾病的诊断定义9，10 和欧洲心脏病学会 （ESC） 最近关于慢性冠脉综合征患者管理的指南提出了根据临床状况进行充分患者评估的建议11.此外，最近的出版物描述了可以从IDP 12，13 衍生的各种内型。这种方法对个体患者有好处，因为随机研究表明，与全科医生的常规护理相比，接受 IDP 然后根据测试结果进行分层药物治疗的患者生活质量更好14。目前，关于检测此类血管舒缩疾病的最合适方案存在争议。本文的目的是描述一种方案，其中乙酰胆碱（ACh）激发试验以寻找冠状动脉痉挛之后，使用腺苷对冠状动脉血流储备（CFR）和充血微血管阻力（HMR）进行基于多普勒线的评估（图1）。
Protocol
冠状动脉内ACh检测已获得当地伦理委员会的批准，该协议遵循我们人类研究机构的指导方针。之前的JoVE文章涵盖了一个方案，显示了ACh溶液的制备以及用于冠状动脉内注射ACh 15的注射器的制备。 1.ACh溶液的制备和冠状动脉内注射ACh注射注射器的制备 请参考之前发表的JoVE文章15。 2.冠状动脉注射用腺苷溶液的?…
Representative Results
根据COVADIS9建议的诊断标准，如果在ACh激发试验期间适用以下标准，则可以诊断血管痉挛性心绞痛：提示缺血的短暂心电图变化，患者通常心绞痛症状的再现以及冠状动脉造影期间确认>心外膜血管90%血管收缩（图2）。 如果在没有心外膜血管痉挛的情况下，在激发试验期间发生患者的症?…
Discussion
心绞痛和冠状动脉畅通患者的管理通常要求很高，有时甚至令人沮丧。在这些患者病情检查过程中的一个重要步骤是充分研究患者症状的潜在病理生理机制。这是具有挑战性的，因为通常不仅有一种机制负责，并且需要考虑各种病因，包括心脏和非心脏以及冠状动脉和非冠状动脉。
通常，不明原因的胸痛患者被安排进行侵入性诊断性冠状动脉造影，以寻找狭窄的心外膜冠状?…
Divulgazioni
The authors have nothing to disclose.
Acknowledgements
该项目得到了德国迪琴根的Berthold-Leibinger基金会的支持。
Materials
| Cannula 0,95 x 50 mm (arterial punction) | BBraun | 4206096 | |
| Cannula 23 G 0,6 x 25 mm (local anesthesia) | BBraun | 4670025S-01 | |
| Coronary angiography suite (AXIOM Artis MP eco) | Siemens | n/a | |
| Contrast agent Imeron 350 with a 10 mL syringe for contrast injection | Bracco Imaging | 30699.04.00 | |
| Diagnostic catheter (various manufacturers) | e.g. Medtronic | DXT5JR40 | |
| Glidesheath Slender 6 Fr | Terumo | RM*RS6J10PQ | |
| Heparin 5,000 IU (25,000 IU / 5 mL) | BBraun | 1708.00.00 | |
| Mepivacaine 10 mg/mL | PUREN Pharma | 11356266 | |
| Sodium chloride solution 0.9 % (1 x 100 mL) | BBraun | 32000950 | |
| Syringe 2 mL (1x) (local anesthesia) | BBraun | 4606027V | |
| Syringe 10 mL (1x) (Heparin) | BBraun | 4606108V | |
| Acetylcholine chloride (vial of 20 mg acetylcholine chloride powder and 1 ampoule of 2 mL diluent) | Bausch & Lomb | NDC 240208-539-20 | |
| Cannula 20 G 70 mm (2x) | BBraun | 4665791 | |
| Glyceryle Trinitrate 1 mg/mL (5 mL) | Pohl-Boskamp | 07242798 | |
| Sodium chloride solution 0.9 % (3 x 100 mL) | BBraun | 32000950 | |
| Syringe 2 mL (1x) | BBraun | 4606027V | |
| Syringe 5 mL (5x) | BBraun | 4606051V | |
| Syringe 10 mL (1x) | BBraun | 4606108V | |
| Syringe 50 mL (3x) | BBraun | 4187903 | |
| Adenosine 6 mg/2 mL | Sanofi-Aventis | 30124.00.00 | |
| ComboMap Pressure/Flow System | Volcano | Model No. 6800 (Powers Up) | |
| Pressure/Flow Guide Wire | Volcano | 9515 | |
| Sodium chloride solution 0.9 % (1 x 100 mL) | BBraun | 32000950 | |
| Syringe 10 mL (3x) | BBraun | 4606108V |
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Citazione di questo articolo
Seitz, A., Beck, S., Pereyra, V. M., Bekeredjian, R., Sechtem, U., Ong, P. Testing Acetylcholine Followed by Adenosine for Invasive Diagnosis of Coronary Vasomotor Disorders. J. Vis. Exp. (168), e62134, doi:10.3791/62134 (2021).