PROLONGED MULTIPLE SPASMS OF SMOOTH CORONARY ARTERIES PRESENTING AS ACUTE MIOCARDIAL INFARCTION, COMPLETE AV BLOCK AND SYNCOPE
Abstract
Background. A variant form of angina pectoris (VAP) is caused by coronary vessel spasm and occures in patients with and without varying degrees of obstructive coronary artery disease. Although the prognosis of VAP without significant organic stenosis is generally good, multivessel spasm is associated with a high risk of life-threatening abnormalities of rhythm and conduction.
Patient and methods. We describe a patient who presented with prolonged chest pain, associated with hypotension, lost of consciousness, complete AV block and widespread ST segment elevations consistent with inferoanterior acute myocardial infarction. Urgent selective coronary angiography revealed spasms in right coronary artery and in left circumflex artery that were relieved by intracoronary injection of nitroglycerin. All coronary arteries were otherwise patient, without signs of atherosclerosis. The patient was treated with diltiazem and nitrates. She made a complete recovery and resumed her normal activities.
Conclusions. Simultaneous multiple spasms of native coronary arteries represent a rare syndrome characterized by significantly higher incidence of potentially life-threatening arrhythmia. Less commonly, prolonged coronary spasm may mimic acute myocardial infarction. Modern management of acute coronary syndromes, including urgent coronarography, enables a prompt differentiation between prolonged coronary spasm and atherosclerotic coronary disease, warranting different treatment strategies. Medical treatment with nitrates and calcium channel blockers in most cases prevents recurrence of vasospasms and arrhythmias.
Downloads
References
Prinzmetal M, Kennamer R, Merliss R, Wada T, Bor N. Angina pectoris. A variant form of angina pectoris. Am J Med 1959; 27: 375–7.
Prinzmetal M, Ekmecki A, Kennamer R, Kwoczynski J, Shubin H, Toyoshima H. Variant form of angina pectoris. Previously undelineated form of angina pectoris. JAMA 1960; 174: 1794–800.
Kerin NZ, Rubenfire M, Naini M, Wajszczuk WJ, Rao P. Prinzmetal’s variant angina: Electrocardiographic and angiographic correlations. J Electrocardiol 1982; 15: 365–80.
Selzer A, Langston M, Ruggeroli C, Cohn K. Clinical syndrome of variant angina with normal coronary arteriogram. N Engl J Med 1976; 295: 1343–7.
Kerin NZ, Rubenfire M, Naini M, Wajszczuk W, Pamatmat A, Cascade P. Arrhythmias in variant angina pectoris: Relation ship of arrhythmias to STsegment elevation and R-wave changes. Circulation 1979; 60: 1343–50.
Haywood LJ, Venkataramen K. Multifocal ischemia, recurrent AV block, and bradycardia with patent coronary arteries responsive to verapamil. J Electrocardiol 1991; 24: 177–83.
Unverdorben M, Haag M, Fuerste T, Weber H, Vallbracht C.Vazospazm in Smoth Coronary Arteries as a Couse of Asystole and Syncope. Cardiovasc Diagn 1997; 41: 430–4.
Puddu PE, Bourassa MG, Waters DD, Lesperance J. Sudden death in two patients with variant angina and apparently minimal fixed coronary stenoses. J Electrocardiol 1983; 16: 213–20.
Miller DD, Waters DD, Szalchich J, Theroux P. Clinical characteristics associated with sudden death in patients with variant angina. Circulation 1982; 66: 588–92.
Previtali M, Ardissino D, Barberis P, Panciroli C, Chimienti M, Salerno JA. Hyperventilation and ergonovine tests in Prinzmetal’s variant angina pectoris in men. Am J Cardiol 1989; 63: 17–20.
Yasue H, Horio Y, Nakamura N, Fujii H, Imoto N, Sonoda R, Kugiyama K, Obata K, Morikami Y, Kimura T. Induction of coronary artery spasm by acetylcholine in patients with variant angina: possible role of the parasympathetic nervous system in the pathogenesis of coronary artery spasm. Circulation 1986; 74: 955–63.
Dunn RF, Kelly DT, Sadick N, Uren R. Multivessel coronary artery spasm. Circulation 1979; 60: 451–5.
Onaka H, Hirota Y, Shimada S, Kita Y, Sakai Y, Kawakami Y, Suzuki S, Kawamura K. Clinical observation of spontaneous anginal attacks and multivessel spasm in variant angina pectoris with normal coronary arteries: Evaluation by 24-hour 12-lead electrocardiography with computer analysis. J Am Coll Cardiol 1996; 27: 38–44.
Miwa K, Fujita M. Alternate coronary artery spasm with ST-segment »seesaw« phenomenon in variant angina. Jpn Circ J 1993; 57: 167–74.
Kerin NZ, Rubenfire M, Willens HJ, Rao P, Cascade PN. The mechanism of dysrhytthmias in variant angina pectoris: Occlusive versus reperfusion. Am Heart J 1983; 106: 1332–40.
Previtali M, Klersy C, Salerno JA, Chimienti M, Panciroli C, Marangoni E, Specchia G, Comolli M, Bobba P. Ventricular tachyarrhythmias in Prinzmetal’s variant angina: clinical significance and relation to the degree and time course of S-T segment elevation. Am J Cardiol 1983; 52: 19–25.
Gillilan RE, Hawley RR, Warbasse JR. Second degree heart block occuring in a patient with Prinzmetal’s variant angina. Am Heart J 1969; 77: 380–2.
Ortega-Carnicer J, Malillos M, Tascon J. Transient bifascicular block during Prinzmetal’s variant angina. Chest 1982; 82: 789–90.
Haywood JL, Venkataramen K. Multifocal ischemia, recurrent AV block, and bradycardia with patent coronary arteries responsive to verapamil. J Electrocardiol 1991; 24: 177–83.
Miwa K, Kambara H, Kawai C. Effect of aspirin in large doses on attacks of variant angina. Am Heart J 1983; 105: 351–5.
Robertson RM, Wood AJJ, Vaughn WK, Robertson D. Exacerbation of vasotonic angina pectoris by propranolol. Circulation 1982; 65: 281–5.
Khatri S, Webb JG, Carere RG, Dodek A. Stenting for coronary artery spasm. Catheter Cardiovasc Interv 2002; 56: 16–20.
Sussman EJ, Goldberg S, Poll DS, Macvaugh H, Simson MB, Silber SA, Kastor JA. Surgical therapy of variant angina associated with nonobstructive coronary disease. Ann Intern Med 1981; 94: 771–4.
Fiocca L, Di Biasi M, Bruno N, Ciuffreda M, Zumbo F, Mangiameli D, Montenero AS. Coronary vasospasm and aborted sudden death treated with an implantable defibrillator and stenting. Ital Heart J 2002; 3: 270–3.
The Author transfers to the Publisher (Zdravniški vestnik/Slovenian Medical Journal) all economic copyrights following form Article 22 of the Slovene Copyright and Related Rights Act (ZASP), including the right of reproduction, the right of distribution, the rental right, the right of public performance, the right of public transmission, the right of public communication by means of phonograms and videograms, the right of public presentation, the right of broadcasting, the right of rebroadcasting, the right of secondary broadcasting, the right of communication to the public, the right of transformation, the right of audiovisual adaptation and all other rights of the author according to ZASP.
The aforementioned rights are transferred non-exclusively, for an unlimited number of editions, for the term of the statutory
The Author can make use of his work himself or transfer subjective rights to others only after 3 months from date of first publishing in the journal Zdravniški vestnik/Slovenian Medical Journal.
The Publisher (Zdravniški vestnik/Slovenian Medical Journal) has the right to transfer the rights, acquired parties without explicit consent of the Author.
The Author consents that the Article be published under the Creative Commons BY-NC 4.0 (attribution-non-commercial) or comparable licence.
