Coronary vasospasm-induced acute coronary syndrome complicated by life-threatening cardiac arrhythmias in patients without hemodynamically significant coronary artery disease

https://doi.org/10.1016/j.ijcard.2006.03.055Get rights and content

Abstract

Background

Coronary vasospasm-induced electrical and mechanical complications in patients with acute coronary syndrome and no hemodynamically significant coronary artery disease are rarely reported.

Methods

A total of 733 consecutive patients with acute coronary syndrome admitted to our hospital who subsequently underwent coronary angiography at our institution were enrolled. Patients who had documented complete atrioventricular block or ventricular fibrillation, no evidence of hemodynamically significant coronary artery disease on coronary angiogram, and no other (non-coronary) cardiac abnormalities were included. Patients were followed for subsequent cardiac events and mortality.

Results

Over a 6-year period at our institution, acute coronary syndrome complicated by life-threatening cardiac arrhythmias developed in six patients who had no hemodynamically significant coronary artery disease with corresponding intra-coronary ergonovine provocative coronary vasospasm. Acute myocardial infarction was diagnosed in five of these patients and variant angina pectoris in one. Complete atrioventricular block was the most common complication in these cases, followed by cardiogenic shock with or without right ventricular infarction, ventricular fibrillation, and severe sinus arrest. These complications were corrected with intravenous fluid, intravenous atropine or cardiac defibrillation. During a median follow-up period of 26 months, none of the patients expired or suffered nonfatal reinfarction. Two individuals who did not stop smoking during follow-up developed recurrent angina after self-discontinuation of calcium antagonists.

Conclusions

Coronary vasospasm can be a cause of life-threatening cardiac arrhythmias in patients with acute coronary syndrome and no hemodynamically significant coronary artery disease. Coronary angiography with/without intra-coronary ergonovine testing is necessary in acute coronary syndrome patients to identify the underlying pathology and establish appropriate treatment in these cases.

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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