Anxiety Score as a Risk Factor for Radial Artery Vasospasm During Radial Interventions

Introduction

The radial artery approach is increasingly used for coronary procedures due to its advantages like early mobilization and patient comfort, but radial artery vasospasm remains a problem. ^{1 –3} Similar efficacy and safety profile compared with the femoral approach resulted in increased use of this technique. This is especially relevant for patients with high bleeding risk such as those receiving intensive antiplatelet, anticoagulant therapies, and fibrinolytics and have a need for emergency coronary intervention. Furthermore, the presence of ulnar artery collaterals decreases the risk of distal embolic and ischemic complications. Many types of coronary, cerebral, vertebral, and renal interventions can be carried out using the radial approach. ^{4 –7}

The radial artery is more vulnerable to vasospasm than other arterial entry sites, since it is rich in smooth muscle and has a comparatively small diameter. The most frequent complication encountered in clinical practice is arm pain due to vasospasm. The incidence of vasospasm is reported as 7.8% to 25%. ^{4,8 –12} These rates are high for a diagnostic procedure and imply the need for risk factor determination before the procedure. Currently, the following variables are identified as risk factors for radial vasospasm: female sex, age, radial artery diameter, and the number of interventions performed. ^{4,8 –12}

Various psychiatric disorders are associated with cardiovascular (CV) diseases. Depressive mood and anxiety are associated with increased rates of CV events. Subclinical CV pathologies are seen more frequently in patients with anxiety. ¹³

Cardiovascular events are capable of triggering psychiatric diseases. In addition, another theory is that a common pathology may trigger both CV events and psychiatric disorders. ¹⁴

We investigated the relationship between vasospasm during radial artery approach and. To our knowledge, no published study investigated this relationship.

Methods

The study was performed in the Department of Cardiology, Gaziantep University School of Medicine, Gaziantep, Turkey. A total of 81 patients were consecutively enrolled between January and June 2012. All patients had an indication for coronary angiography (eg, unstable angina and angina resistant to medical therapy). We did not include patients with acute myocardial infarction. The Allen test was satisfactory for each patient. Our clinic is a tertiary center where an average of 3500 coronary angiographies or interventions are performed each year, and we have an increasing experience with the radial approach for nearly 8 years. The percentage of radial approach in our center is about 20% of all coronary interventions. All procedures were performed by operators experienced with radial interventions (radial approach used in >40% of their cases). Approval of local ethics committee was obtained before starting the study.

Results

The male to female ratio was 45:36. Mean age for men and women were 55.9 ± 12 (range 30-78) and 55.9 ± 10 (35-79) years, respectively. Mean anxiety score of the whole study population was 14.0 ± 7.9 (2-31). The score was 17.6 ± 7.3 (2-31) for women and 11.1 ± 7.2 (2-30) for men. Anxiety score was significantly higher in women (P < .001; Table 1).

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Table 1.

Comparison of Male and Female Patients Who Underwent Radial Coronary Angiography.

	Male (n = 45)	Female (n = 36)	P Value
Age, years	55.9 ± 12	55.9 ± 10	NS
Anxiety score	11.1 ± 7.2	17.6 ± 7.3	<.001
Vasospasm, %	4.4%	38.4%	<.001
Height, cm	172.1 ± 7.4	162.5 ± 6.5	<.001
Weight, kg	87.2 ± 13.6	79.8 ± 14.4	NS
Body mass index, kg/m2	29.4 ± 4.3	30.2 ± 5.3	NS

Abbreviation: NS, nonsignificant.

Vasospasm was observed in 19.1% of the population. The rate of vasospasm was 4.4% for men and 38.4% for women (P < .001). Vasospasm was strongly correlated with female sex (P < .001, r = .43). There was also a strong correlation between vasospasm and higher anxiety score (P = .007, r = .29). Female sex was associated with higher anxiety scores (P < .001, r = .43). However, age was associated neither with anxiety score nor with vasospasm (P > .05). Multivariate regression analysis revealed that female sex and high anxiety score independently predict radial artery spasm (P = .001 and P = .017, respectively).

Discussion

We evaluated the association between the degree of anxiety and vasospasm during transradial procedures. The rate of vasospasm among patients undergoing coronary angiography via radial artery route was 19.1%. Vasospasm was more frequent in female patients and significantly correlated with the anxiety score.

Recently a comprehensive consensus document on the increasing role of radial approach in percutaneous CV interventions was published. ¹⁶ However, arm pain due to vasospasm is an important consideration. Intensive sympathetic alpha-receptor density found in the radial artery is accepted as the primary determinant for vasospasm. ¹⁷ In addition, dysregulation of serotonin and nitric oxide levels triggered by endothelial dysfunction contribute to vasospasm. ¹⁰ Symptoms seen in patients with anxiety are triggered by increased sympathetic tone, which leads to increased circulating levels of catecholamines. ^{18 –20} Our study suggests that higher anxiety score is an important risk factor for radial artery vasospasm possibly triggered by increased sympathetic tone in patients with high anxiety scores.

Studies revealed that patients with psychiatric disorders demonstrate anomalous blood flow properties related to endothelial dysfunction. ^10,13,14 Spasmolytic cocktails are recommended to prevent vasospasm. The SPASM trial (Prevention of arterial spasm during percutaneous coronary interventions through radial artery: The SPASM Study) showed that verapamil and molsidomin significantly reduced the rates of vasospasm in patients undergoing coronary angiography via the radial route. ²¹ Vefali et al concluded that the procedural success rate of radial approach is similar to that of the femoral approach. ²² Despite not using any vasodilator agents, they reported that only 1 patient experienced vasospasm among 487 patients. However, the operators in this study routinely used premedication sedation with midazolam.

A recent study demonstrated that preprocedural administration of opioid analgesia combined with sedation (fentanyl and midazolam) significantly reduced the incidence of radial artery spasm during transradial procedures. ²³ Although these investigators did not assess the anxiety score, their study implicates a possible role of sedation in preventing radial artery spasm during the procedure. This study supports our findings that underscore the relationship between high anxiety score and radial artery spasm.

In addition, minimally invasive procedures like endoscopic procedures, dental interventions, coronary angiography, and pediatric echocardiography are performed with greater success rates with the help of midazolam as an anxiolytic agent. ^24,25 Along with the sedative effect, midazolam also suppresses sympathetic reflex response in animal models. ^26,27 We used calcium channel blockers before the procedure in our study. Persistently high basal levels of catecholamines seen in anxiety facilitate radial artery vasospasm, which is rich in alpha-receptors, and also reduce the effectiveness of calcium channel blockers in preventing vasospasm.

Population-based studies revealed that anxiety is seen 2 times more frequently in females. ^28,29 In our study, anxiety score was consistently higher in female participants and accordingly, vasospasm was more frequent in women. The SPASM trial also documented that female sex and younger age were independent predictors of vasospasm in transradial procedures. ²¹ Higher frequency of vasospasm seen in women was attributed to increased anxiety scores in the present study. In contrast to previous studies, age was not associated with vasospasm in our study. This may be related to the finding that age was not associated with anxiety score.

Findings from previous studies suggest that small radial artery diameter was also associated with vasospasm. Small radial artery diameter observed in women also has a role in higher rates of vasospasm in this gender. ^30,31 Vasospasm risk is reduced with smaller diameter cannulations ³² ; however, percutaneous coronary interventions performed with greater diameter catheters provide greater success rates. ³³

Anxiety score across different populations varies considerably. Sartorius et al studied 25 000 patients from 15 different countries and found that the prevalence of anxiety was 10.5%. ³⁴ Different rates of vasospasm reported in the literature during radial procedures can also be explained in part by different populations and ethnicity. ³⁵ Despite the fact that vasospasm was more common among subgroups with high anxiety score, it remains to be established whether anxiety was the causative factor for vasospasm