Prinzmetal angina. Multifocal ischemia, recurrent AV block, and bradycardia with patent coronary arteries responsive to verapamil

Bloqueo auriculoventricular en la angina inestable. Resultados del registro ARIAM

OBJECTIVE

Describe the frequency of high degree atrioventricular block (HDAVB) in patients with unstable angina (UA), analyze the variables associated with their appearance and evaluate whether HDAVB is independently associated with increased mortality or increased length of ICU stay.

DESIGN

Retrospective descriptive study of patients with UA included in the ARIAM registry.

SETTING

ICUs from 129 hospitals in Spain.

PATIENTS

From June 1996 to December 2003 a total of 14,096 patients were included in the ARIAM registry with a diagnosis of UA.

MAIN VARIABLES OF INTEREST

Variables associated with the development of HDAVB, variables associated with the mortality of patients with UA, variables associated with the length of ICU stay of patients with UA.

RESULTS

HDAVB frequency was 1%. Development of HDAVB was independently associated with the Killip classification and the presence of sustained ventricular tachycardia or ventricular fibrillation. Crude mortality of patients was significantly increased when HDAVB was present (9% versus 1%, p < 0,001). When adjusted for other variables, HDAVB was not associated with increased mortality. Development of HDAVB in patients with UA was independently associated with an increase in the length of ICU stay (adjusted odds ratio 1.89: 95% confidence interval: 1.33-5.69).

CONCLUSIONS

Patients with UA complicated with HDAVB represent a high-risk population with an increased ICU stay.

Intra- and postoperative myocardial ischemia without significant coronary artery stenosis

A 73-year-old man without a history of coronary artery disease had two episodes of significant ST-segment elevation indicative of inferior myocardial ischemia during the resection of an abdominal aortic aneurysm. During the further course, sudden ST-segment elevations occurred and resolved spontaneously without preceding hemodynamic instability. The patient sustained two episodes of cardiac arrest due to ventricular fibrillation and intermittent third-degree atrioventricular block with ventricular asystole. On cardiac catheterization, coronary arteries had a right dominant pattern. The right coronary artery was entirely patent on multiple injections. Thus, right coronary artery spasm is the only possible explanation for these observations.