Coronary vasospasm-induced acute coronary syndrome complicated by life-threatening cardiac arrhythmias in patients without hemodynamically significant coronary artery disease
Introduction
It has been shown that coronary vasospasm plays an important role in the pathogenesis of not only variant angina but also ischemic heart disease in general, including other forms of angina pectoris and acute myocardial infarction as well as sudden death [1], [2], [3], [4]. Vasoactive events, leading to acute reduction in regional myocardial flow in the presence of a normal or previously compromised circulation, are a common cause of arrhythmias [5]. Coronary vasospasm-induced electrical and mechanical complications in patients with acute coronary syndrome and angiographically normal coronary arteries, however, are rarely reported [6], [7], [8], [9]. It is important to identify the predominant factor causing these symptoms/signs as the choice of treatment will vary. In this report, we present our experience with patients presenting with acute coronary syndrome [unstable angina or acute myocardial infarction (AMI)] complicated by coronary vasospasm-related life-threatening arrhythmias but found to have no hemodynamically significant coronary artery disease.
Section snippets
Patient selection
Consecutive patients with acute coronary syndrome admitted to our hospital who subsequently underwent coronary angiography from June 1998 to May 2004 were enrolled. The study inclusion criteria were patients who met all of the following: 1) clinical diagnosis of unstable angina or AMI; 2) documented complete atrioventricular block or ventricular fibrillation; 3) no evidence of hemodynamically significant coronary artery disease on coronary angiogram; and, 4) no other (non-coronary) cardiac
Results
A total of 733 consecutive patients with acute coronary syndrome underwent cardiac catheterization at our institution and of this group, 186 patients (25%) were recorded as having no hemodynamically significant coronary artery disease. All of these 186 patients underwent intra-coronary ergonovine testing immediately after coronary angiography.
Six patients (3.2%) in this hemodynamically insignificant coronary artery disease group developed severe sinus arrest, complete atrioventricular block
Discussion
This observational study had three potentially important findings. Firstly, coronary vasospasm is a cause of life-threatening complications in cases of acute coronary syndrome without hemodynamically significant coronary artery disease. Secondly, coronary angiography with/without intra-coronary ergonovine provocation testing is a prerequisite for correct management because of the variation in the etiologies underlying coronary vasospasm and hemodynamically significant coronary artery disease in
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