RESUMO
A 60-year-old man was referred to our hospital presenting with unconsciousness due to severe hyponatremia. The twelvelead ECG on admission exhibited prominent J waves in the inferolateral leads. During the treatment for hyponatremia, ventricular fibrillation (VF) occurred and the electrogram (ECG) after the VF incident exhibited marked ST elevation in the inferolateral leads. An Ach provocation test induced vasospasms in the right and left coronary arteries and J wave augmentation, suggesting a high risk for vasospastic angina. Finally, a subcutaneous implantable cardioverter defibrillator was implanted in the patient. We hereby discuss the possible contribution of hyponatremia to VF episodes in early repolarization syndrome based on the present case.
Assuntos
Vasoespasmo Coronário , Eletrocardiografia , Hiponatremia , Fibrilação Ventricular , Humanos , Masculino , Fibrilação Ventricular/etiologia , Fibrilação Ventricular/fisiopatologia , Fibrilação Ventricular/diagnóstico , Pessoa de Meia-Idade , Hiponatremia/etiologia , Vasoespasmo Coronário/fisiopatologia , Vasoespasmo Coronário/diagnóstico , Vasoespasmo Coronário/complicações , Desfibriladores Implantáveis , SíndromeRESUMO
Although long-QT syndrome (LQTS) with a normal range QT interval at rest leads to fatal ventricular arrhythmias, it is difficult to diagnose. In this article, we present a rare case of a patient who suffered a cardiac arrest and was recently diagnosed with LQTS and coronary vasospasm. A 62-year-old man with no syncopal episodes had a cardiopulmonary arrest while running. During coronary angiography, vasospasm was induced and we prescribed coronary vasodilators, including calcium channel blockers. An exercise stress test was performed to evaluate the effect of medications and accidentally unveiled exercise-induced QT prolongation. He was diagnosed with LQTS based on diagnostic criteria. Pharmacotherapy and an implantable cardioverter defibrillator were used for his medical management. It is extremely rare for LQTS and coronary vasospasm to coexist. In cases of exercise-induced arrhythmic events, the exercise stress test might be helpful to diagnose underlying disease.
Assuntos
Vasoespasmo Coronário , Parada Cardíaca , Síndrome do QT Longo , Masculino , Humanos , Pessoa de Meia-Idade , Fibrilação Ventricular/complicações , Fibrilação Ventricular/diagnóstico , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/diagnóstico , Eletrocardiografia , Síndrome do QT Longo/complicações , Síndrome do QT Longo/diagnóstico , Arritmias Cardíacas/complicações , Parada Cardíaca/complicaçõesRESUMO
Vasospastic angina (VSA) refers to chest pain experienced as a consequence of myocardial ischaemia caused by epicardial coronary spasm, a sudden narrowing of the vessels responsible for an inadequate supply of blood and oxygen. Coronary artery spasm is a heterogeneous phenomenon that can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction (MI). VSA was originally described as Prinzmetal angina or variant angina, classically presenting at rest, unlike most cases of angina (though in some patients, vasospasm may be triggered by exertion, emotional, mental or physical stress), and associated with transient electrocardiographic changes (transient ST-segment elevation, depression and/or T-wave changes). Ischaemia with non-obstructive coronary arteries (INOCA) is not a benign condition, as patients are at elevated risk of cardiovascular events including acute coronary syndrome, hospitalization due to heart failure, stroke and repeat cardiovascular procedures. INOCA patients also experience impaired quality of life and associated increased healthcare costs. VSA, an endotype of INOCA, is associated with major adverse events, including sudden cardiac death, acute MI and syncope, necessitating the study of the most effective treatment options currently available. The present literature review aims to summarize current data relating to the diagnosis and management of VSA and provide details on the sequence that treatment should follow.
Diagnosis and treatment of epicardial coronary artery spasmVasospastic angina (VSA) refers to chest pain experienced as a consequence of a sudden narrowing of the epicardial coronary arteries. VSA can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction. Reduced blood and oxygen supply in patients with non-obstructive coronary arteries is not a benign condition, as patients are at elevated risk of adverse cardiovascular events. These patients also experience impaired quality of life and associated increased healthcare costs. This review aims to summarise current data relating to the diagnosis of VSA and provides details on treatment strategies.
Assuntos
Angina Pectoris Variante , Doença da Artéria Coronariana , Vasoespasmo Coronário , Infarto do Miocárdio , Humanos , Angina Pectoris Variante/diagnóstico , Angina Pectoris Variante/terapia , Angina Pectoris Variante/complicações , Vasoespasmo Coronário/diagnóstico , Vasoespasmo Coronário/terapia , Vasoespasmo Coronário/complicações , Qualidade de Vida , Angiografia Coronária/efeitos adversos , Dor no Peito/complicações , Espasmo/complicaçõesRESUMO
Chest pain is the most common symptom of coronary artery disease (CAD) and diabetes mellitus (DM) is a well-known single strongest risk factor for cardiovascular diseases. Thus, the impact of CAD nor DM on long-term clinical effects is reported widely, but the prognostic factors of non-DM patients presenting with chest pain without significant CAD are limited. A total of 1,046 patients with chest pain without DM and significant CAD who underwent coronary angiography (CAG) and acetylcholine (ACH) provocation tests were finally enrolled. Propensity score matching and multivariate Cox-proportional hazard ratio analysis were performed to adjust for baseline potential confounders. Major adverse cardiac and cerebrovascular events (MACCE) were defined as the composite of total death, myocardial infarction (MI), revascularization, stroke, and recurrent angina. This study aimed to evaluate the long-term prognostic factors for MACCE in patients with chest pain without DM and CAD up to 5 years. Coronary artery spasm (CAS) was the most common cause of chest pain. However, long-term MACCE of CAS was not worse than those of patients with chest pain without CAS when patients with CAS had subsequent optimal antianginal medication therapy. However, a recurrent chest pain remains a problem even with continuous antianginal medication therapy. Up to 5 years, the incidence of MACCE was in 7.3%, including recurrent angina 6.9%. Dyslipidemia (HR: 2.010, 95% CI 1.166-3.466, P = 0.012), mild-moderate (30-70%) coronary stenosis (HR: 2.369, 95% CI 1.118-5.018, P = 0.024), the use of aspirin (HR: 2.885, 95% CI 1.588-5.238, P < 0.001), and the use of nitrates (HR: 1.938, 95% CI 1.094-3.433, P = 0.023) were independent risk factors for MACCE. Among the patients with chest pain without DM and significant CAD, the incidence of MACE were rare, but recurrent angina was still a challenging problem who had treated with antianginal medications.
Assuntos
Fármacos Cardiovasculares , Doença da Artéria Coronariana , Estenose Coronária , Vasoespasmo Coronário , Diabetes Mellitus , Humanos , Prognóstico , Doença da Artéria Coronariana/complicações , Angina Pectoris/diagnóstico , Angina Pectoris/epidemiologia , Angina Pectoris/etiologia , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/diagnóstico , Vasoespasmo Coronário/epidemiologia , Estenose Coronária/diagnóstico , Estenose Coronária/diagnóstico por imagem , Dor no Peito/diagnóstico , Dor no Peito/epidemiologia , Dor no Peito/etiologia , Diabetes Mellitus/epidemiologia , Fatores de Risco , Angiografia Coronária/efeitos adversosRESUMO
Increasing evidence has shown that coronary spasm and vasomotor dysfunction may be the underlying cause in more than half of myocardial infarctions with non-obstructive coronary arteries (MINOCA) as well as an important cause of chronic chest pain in the outpatient setting. We review the contemporary understanding of coronary spasm and related vasomotor dysfunction of the coronary arteries, the pathophysiology and prognosis, and current and emerging approaches to diagnosis and evidence-based treatment.
Assuntos
Vasoespasmo Coronário , MINOCA , Humanos , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/diagnóstico por imagem , Dor no Peito , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/cirurgia , EspasmoRESUMO
RATIONALE: Diffuse multivessel coronary artery spasm (DMV-CAS) was defined as a severe and reversible diffuse spasm occurring in more than 2 major coronary arteries, which is rare in clinical practice. Due to a wide lesion scope, DMV-CAS often occurs in the form of complications. It is not easy to be clinically diagnosed because it is too brief to be caught. Here, we report a rare case of spontaneous subtotal occlusion of 3 major coronary arteries induced by Vasalva action, which was confirmed in real-time by CAG. PATIENT CONCERNS: A 68-year-old man had sudden chest pain after forced defecation during hospitalization. The electrocardiogram showed transient ST segment elevation of the inferior wall lead, inversion of the anterior wall, and lateral wall leads T waves. Emergency CAG revealed elongated vessel beds in 3 coronary arteries and multiple diffuse stenosis, but none of the coronary arteries were completely occlusive. DIAGNOSES: Diagnoses of DMV-CAS were made based on CAG findings and postmedication response. INTERVENTIONS: Nitroglycerin was administered in the coronary arteries. The anti-vasospasm, antiplatelet aggregation and lipid-regulating drugs were administered orally. OUTCOMES: The patient was discharged on the 7th day with complete resolution of symptoms and normalization of the electrocardiography findings. No ischemic events occurred during a follow-up for 5 months. LESSONS: This case highlights the identification of multivessel diffuse coronary spasm and acute myocardial infarction, and the prevention of CAS triggers, which requires the attention of clinicians.
Assuntos
Vasoespasmo Coronário , Infarto do Miocárdio , Masculino , Humanos , Idoso , Vasos Coronários/diagnóstico por imagem , Angiografia Coronária/efeitos adversos , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/diagnóstico , Infarto do Miocárdio/complicações , Nitroglicerina/uso terapêutico , Eletrocardiografia , Arritmias Cardíacas/tratamento farmacológicoAssuntos
Vasoespasmo Coronário , Fístula Gástrica , Pericárdio , Humanos , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/diagnóstico por imagem , Fístula Gástrica/etiologia , Fístula Gástrica/diagnóstico por imagem , Fístula Gástrica/complicações , Pericárdio/diagnóstico por imagem , Masculino , Angiografia Coronária , Fístula/complicações , Fístula/diagnóstico por imagem , Cardiopatias/complicações , Cardiopatias/diagnóstico por imagem , Cardiopatias/etiologia , Pessoa de Meia-IdadeRESUMO
BACKGROUND Although coronary artery disease and coronary artery spasm (CAS) can lead to acute myocardial infarction, there are clear differences in treatment between coronary heart disease and CAS, and the therapeutic schedule should not be confused. Furthermore, electrocardiogram (ECG) "6+2" phenomenon is recommend as a specific ECG indicator for lesions in the left main coronary artery or multiple vessels. Currently, no reports of this phenomenon in CAS exist. CASE REPORT A 72-year-old man had history of recurrent chest pain for over 6 years, with episodes lasting about 10 min and resolving with rest. He experienced symptom recurrence and exacerbation due to substance abuse. He was admitted to our Emergency Department for chest pain at rest. His emergency ECG revealed a 6+2 phenomenon, accompanied by troponin levels exceeding 18 times the reference value. Promptly, we conducted coronary angiography, with unexpected normal findings. Following thorough assessment, we postulated the patient could have CAS. Subsequent to medical team intervention, the patient's ECG normalized, leading to his discharge upon condition stabilization. CONCLUSIONS We report a case of CAS in a patient with ECG 6+2 phenomenon, without significant coronary artery stenosis. This differs from transient ST-segment elevation on ECG, a well-recognized hallmark of CAS; however, such a presentation has not been documented before. Additionally, treatment strategies for myocardial ischemic conditions stemming from coronary atherosclerosis diverge from those employed for CAS. Therefore, clinicians should advocate for coronary angiography whenever feasible. This approach serves to elucidate the underlying disease etiology and facilitates the administration of precision-targeted interventions for patients.
Assuntos
Doença da Artéria Coronariana , Vasoespasmo Coronário , Infarto do Miocárdio , Masculino , Humanos , Idoso , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/terapia , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/diagnóstico , Vasoespasmo Coronário/terapia , Eletrocardiografia , Infarto do Miocárdio/diagnóstico , Dor no Peito/etiologia , Angiografia CoronáriaRESUMO
RATIONALE: Kounis syndrome is a rare but life-threatening anaphylactic reaction that can lead to acute coronary syndrome and cardiac arrest, and requires prompt diagnosis. Adrenaline, which is used to treat anaphylaxis, may cause coronary vasoconstriction and worsen ischemia, whereas coronary vasodilators may dilate systemic vessels and exacerbate hypotension. Delayed diagnosis of Kounis syndrome and inadequate therapeutic intervention may thus lead to a poor outcome. PATIENT CONCERNS: A 59-year-old man was treated for sepsis due to a liver abscess. Following administration of daptomycin, the patient developed severe anaphylactic shock leading to refractory cardiac arrest. Because conventional cardiopulmonary resuscitation was ineffective, extracorporeal cardiopulmonary resuscitation was considered as an alternative approach. DIAGNOSES: On bedside monitoring during cardiopulmonary resuscitation, unexpected ST-segment elevation was found on lead II electrocardiogram. Accordingly, the patient was clinically diagnosed with Kounis syndrome. INTERVENTIONS: Nicorandil (6 mg/h), a coronary vasodilator with minimal blood pressure effects, was administered along with high doses of vasopressors, including adrenaline 0.2 µg/kg/min. OUTCOMES: After the initiation of nicorandil administration, the patient achieved return of spontaneous circulation and did not require extracorporeal cardiopulmonary resuscitation. Based on the elevated serum tryptase level, normal creatine kinase-MB range, and lack of stenosis on coronary angiography, the patient was definitively diagnosed with type I (coronary vasospasm) Kounis syndrome. He was subsequently transferred to the referring hospital without neurological sequelae. LESSONS: If anaphylaxis leads to refractory shock and cardiac arrest, ischemic changes on the electrocardiogram should be investigated to identify underlying Kounis syndrome. In addition to adrenaline, coronary dilators are the definitive treatment. Nicorandil may be a useful treatment option because of its minimal effect on blood pressure.
Assuntos
Anafilaxia , Vasoespasmo Coronário , Parada Cardíaca , Síndrome de Kounis , Masculino , Humanos , Pessoa de Meia-Idade , Epinefrina/efeitos adversos , Nicorandil/efeitos adversos , Anafilaxia/induzido quimicamente , Anafilaxia/tratamento farmacológico , Anafilaxia/complicações , Síndrome de Kounis/tratamento farmacológico , Síndrome de Kounis/etiologia , Síndrome de Kounis/diagnóstico , Parada Cardíaca/induzido quimicamente , Parada Cardíaca/terapia , Vasodilatadores/uso terapêutico , Vasoespasmo Coronário/induzido quimicamente , Vasoespasmo Coronário/tratamento farmacológico , Vasoespasmo Coronário/complicaçõesRESUMO
Although heart failure (HF) is a clinical syndrome that becomes worse over time, certain cases can be reversed with appropriate treatments. While coronary artery spasm (CAS) is still underappreciated and may be misdiagnosed, ischemia due to coronary artery disease and CAS is becoming the single most frequent cause of HF worldwide. CAS could lead to syncope, HF, arrhythmias, and myocardial ischemic syndromes such as asymptomatic ischemia, rest and/or effort angina, myocardial infarction, and sudden death. Albeit the clinical significance of asymptomatic CAS has been undervalued, affected individuals compared with those with classic Heberden's angina pectoris are at higher risk of syncope, life-threatening arrhythmias, and sudden death. As a result, a prompt diagnosis implements appropriate treatment strategies, which have significant life-changing consequences to prevent CAS-related complications, such as HF. Although an accurate diagnosis depends mainly on coronary angiography and provocative testing, clinical characteristics may help decision-making. Because the majority of CAS-related HF (CASHF) patients present with less severe phenotypes than overt HF, it underscores the importance of understanding risk factors correlated with CAS to prevent the future burden of HF. This narrative literature review summarises and discusses separately the epidemiology, clinical features, pathophysiology, and management of patients with CASHF.
Assuntos
Vasoespasmo Coronário , Insuficiência Cardíaca , Humanos , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/diagnóstico , Síndrome , Angina Pectoris , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/etiologia , Arritmias Cardíacas , Angiografia Coronária , Morte Súbita , Vasos CoronáriosRESUMO
Coronary artery spasm (CAS) is a dynamic coronary stenosis causing vasospastic angina (VSA). However, VSA is a potentially lethal medical condition with multiple presentations, including sudden cardiac death. Despite investigations to explore its pathogenesis, no single mechanism has been found to explain the entire process of VSA occurrence. The roles of elevated local and systemic inflammation have been increasingly recognized in VSA. Treatment strategies to decrease local and systemic inflammation deserve further investigation.
Assuntos
Vasoespasmo Coronário , Humanos , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/epidemiologia , Angina Pectoris/epidemiologia , Angina Pectoris/etiologia , Inflamação/complicações , Angiografia CoronáriaRESUMO
A man in his 40s who was previously well had an out-of-hospital cardiac arrest. Postresuscitation ECG showed ST-elevation myocardial infarction (MI). Emergency coronary angiogram revealed MI with non-obstructive coronary arteries (MINOCA) with evidence of spasm in the right coronary artery. Both his echocardiogram and cardiac MRI revealed a normal heart. Further workup showed markedly elevated free T4 (99.5 pmol/L) and free T3 (26.7 pmol/L) with low thyroid stimulating hormone (<0.02 pmol/L) in keeping with thyroid storm. He also had an elevated adjusted calcium level (2.84 mmol/L), which could have contributed to his coronary artery spasm. His peak troponin T was elevated at 798 ng/L (<14) suggesting myocardial damage. He was treated with propylthiouracil, steroids, beta-blocker, calcium channel blocker and intravenous fluids. The patient achieved a full recovery and was discharged home. This is an unusual case of thyroid dysfunction resulting in coronary artery spasm, cardiac arrest and MINOCA.
Assuntos
Vasoespasmo Coronário , Parada Cardíaca , Masculino , Humanos , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/diagnóstico por imagem , MINOCA , Vasos Coronários/diagnóstico por imagem , Angiografia Coronária , Parada Cardíaca/complicaçõesRESUMO
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is a disorder characterized by recurrent thunderclap headaches and reversible cerebral vasoconstriction. CASE REPORT Herein, we present the case of a man in his forties with a disease entity related to RCVS accompanied by vasospasm of the extracerebral blood vessels throughout the body. The patient presented to the Emergency Department with a severe headache and epigastric pain. Initially receiving a misdiagnosis of functional pain, he continued to experience severe recurrent headaches, most often after urinating or defecating and was referred to our department. Suspecting RCVS, we performed magnetic resonance angiography, which revealed beaded irregularity in the right anterior cerebral and V4 vertebral arteries. The patient also had epigastric pain that coincided with each headache. Electrocardiography revealed pronounced ST-segment elevation in leads I and aVL and inverted T wave in lead III, while abdominal computed tomography angiography showed narrowing of the colic arteries. We named this disease "reversible systemic vasoconstriction syndrome" (RSVS) as a potential suggested terminology for the future. CONCLUSIONS RSVS is a clinical syndrome characterized by thunderclap headaches and simultaneous unbearable pain in extracerebral organs. To the best of our knowledge, this is the first case report of RCVS with coronary and colic artery vasospasm. We need to take great care of patients with chest or abdominal pain accompanied by recurrent thunderclap headaches, since they can be misdiagnosed with functional or psychogenic disorders.
Assuntos
Transtornos Cerebrovasculares , Cólica , Vasoespasmo Coronário , Vasoespasmo Intracraniano , Masculino , Humanos , Vasoconstrição , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/diagnóstico , Cólica/complicações , Vasoespasmo Intracraniano/diagnóstico , Vasoespasmo Intracraniano/diagnóstico por imagem , Angiografia por Ressonância Magnética , Cefaleia/etiologia , Dor , Artérias/patologiaRESUMO
RATIONALE: Coronary artery spasm (CAS) defined by severe reversible focal or diffuse vasoconstriction, plays an essential role in the pathophysiology of acute coronary syndrome but is not very common in the clinic. Due to its transience, it is difficult to diagnose CAS directly, many patients are diagnosed by clinical experience. Here, we report the diagnosis and treatment of a rare case of simultaneous total occlusion due to spasm of the two main coronary arteries by coronary angiography (CAG). PATIENT CONCERNS: A 47-year-old man with no medical history was admitted to our emergency room complaining of sudden-onset chest pain lasting 3 hours. Emergency CAG showed total occlusion of the proximal left anterior descending artery and right coronary artery. DIAGNOSES: Acute myocardial infarction caused by CAS was diagnosed, according to CAG findings and test results. INTERVENTIONS: Intracoronary injection of nitroglycerin and anti-spasm medication. OUTCOMES: The patient was discharged on the 8th day with complete resolution of symptoms and normalization of the electrocardiography findings. No ischemic events occurred during a follow-up for 27 months. LESSONS: This case highlights the significance of identifying CAS in patients with acute myocardial infarction and avoiding blind interventional stent therapy, which requires closer attention from clinicians.
Assuntos
Vasoespasmo Coronário , Infarto do Miocárdio , Masculino , Humanos , Pessoa de Meia-Idade , Vasos Coronários/diagnóstico por imagem , Infarto do Miocárdio/etiologia , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/diagnóstico , Vasoespasmo Coronário/terapia , Nitroglicerina/uso terapêutico , Angiografia Coronária/efeitos adversos , EletrocardiografiaAssuntos
Doença da Artéria Coronariana , Vasoespasmo Coronário , Placa Aterosclerótica , Humanos , Vasoespasmo Coronário/complicações , Vasoespasmo Coronário/diagnóstico por imagem , Vasoespasmo Coronário/tratamento farmacológico , Resultado do Tratamento , Doença da Artéria Coronariana/complicações , Hemorragia/diagnóstico por imagem , Hemorragia/etiologia , Vasos Coronários/diagnóstico por imagem , Tomografia de Coerência ÓpticaRESUMO
We present a case of recurrent vasospasm as an uncommon cause of ventricular fibrillation in a young female patient who was found to have a genetic mutation of unknown significance in the desmoplakin (DSP) gene and ultimately required an implantable cardiac defibrillator and percutaneous coronary intervention. Refractory vasospasm as a cause of chest pain and cardiac arrest may be under-recognised. In this manuscript, we highlight the natural history of refractory vasospasm, treatment considerations including medical therapy, implantable cardiac defibrillator and percutaneous coronary intervention. Lastly, we explore the potential correlation between the DSP mutation and her clinical presentation and the growing importance of genetic testing in unexplained cardiac arrest.