Acetylcholine provocation testing can help predict major adverse CV and cerebrovascular events

A new study conducted by Rocco Antonio Montone and team found that in both ischemia with non-obstructive coronary arteries (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA) patients, the frequency of moderate and temporary problems during acetylcholine (ACh) provocation testing is comparable. The findings of this study were published in EuroIntervention.

For individuals with suspected myocardial ischemia and non-obstructive coronary arteries, intracoronary provocation testing with acetylcholine is essential for the identification of functional coronary abnormalities. The purpose of this study was to evaluate the safety and predictive value of major adverse cardiovascular and cerebrovascular events (MACCE) in patients who presented with myocardial infarction or ischemia with non-obstructive coronary arteries.

For this investigation, INOCA or MINOCA patients who were having intracoronary acetylcholine provocation testing were prospectively included.

The key findings of this study were:

1. There were 317 patients enrolled in all, 174 (54.9%) of whom received INOCA, while 143 (45.1%) received MINOCA. 185 of these individuals (58.4%) responded well to the ACh test.

2. There was no difference between patients who had positive or negative reactions to the ACh testing, nor between INOCA and MINOCA patients, when it came to complications during ACh provocative testing.

3. They were all minor and temporary, and they affected 29 (9.1%) of the patients.

4. Independent risk factors for problems were a history of paroxysmal atrial fibrillation, moderate to severe diastolic dysfunction, and a larger QT dispersion on the baseline ECG. 30 individuals (9.5%) with a median follow-up of 22 months experienced MACCE.

5. A positive ACh test was an independent predictor of MACCE and was associated with a greater frequency of MACCE in patients.

In conclusion, there may be a net therapeutic advantage from doing ACh provocation testing in this clinical environment as it can help identify individuals who are more likely to experience subsequent clinical events.

Reference: 

Montone, R. M., Rinaldi, R., Del Buono, M. G., Gurgoglione, F., La Vecchia, G., Russo, M., Caffè, A., Burzotta, F., Leone, A. M., Romagnoli, E., Sanna, T., Pelargonio, G., Trani, C., Lanza, G. A., Niccoli, G., & Crea, F. (2022). Safety and prognostic relevance of acetylcholine testing in patients with stable myocardial ischaemia or myocardial infarction and non-obstructive coronary arteries. In EuroIntervention (Vol. 18, Issue 8, pp. e666–e676). Europa Digital & Publishing. https://doi.org/10.4244/eij-d-21-00971