Pre-hospital cardiac arrest associated with coronary artery spasm

Surgical reconstruction of the left main coronary artery with patch-angioplasty

Background

Conventional coronary artery bypass grafting (CABG) has been established as the treatment of choice for left main coronary artery (LMCA) stenosis However, the conventional grafting provides a retrograde perfusion to extensive myocardial area and leads prospectively to competitive flow of the non-occluded coronaries thus consuming the grafts. Surgical reconstruction of the LMCA with patch-angioplasty is an alternative method that eliminates these drawbacks.

Methods

Between February 1997 and July 2007, 37 patients with isolated LMCA stenosis were referred for surgical ostial reconstruction. In 27 patients (73%) surgical angioplasties have been performed. All patients were followed up clinically and with transesophageal echocardiography (TEE) and coronary angiography when required.

Results

In 10 patients (27%) a LMCA stenosis could not be confirmed. There were no early mortality or perioperative myocardial infarctions. The postoperative course was uneventful in all patients. In 25 patients, TEE demonstrated a wide open main stem flow pattern one to six months after reconstruction of the left main coronary artery with one patch mild aneurysmal dilated.

Conclusions

The surgical reconstruction with patch-angioplasty is a safe and effective method for the treatment of proximal and middle LMCA stenosis. Almost one third of the study group had no really LMCA stenosis: antegrade flow pattern remained sustained and the arterial grafts have been spared. In the cases of unclear or suspected LMCA stenosis, cardio-CT can be performed to unmask catheter-induced coronary spasm as the underlying reason for isolated LMCA stenosis.

Coronary vasospasm as a possible cause of elevated cardiac troponin I in patients with acute coronary syndrome and insignificant coronary artery disease

BACKGROUND

Abnormal levels of serum cardiac troponin I (cTnI) are occasionally found in patients presenting with acute coronary syndromes but having insignificant coronary artery disease. Before one concludes that an abnormal cTnI level is a false-positive result, the possibility of coronary vasospasm should be considered. This study investigated whether coronary vasospasm could be a reason for elevated cTnI in this patient population.

METHODS AND RESULTS

This investigation enrolled 93 patients who presented to the emergency department with suspected coronary ischemia and had insignificant coronary artery disease. cTnI was elevated in 23 patients (25%) and was normal in 70 patients (75%). Coronary vasospasm, documented by an ergonovine provocation test, was found in 38 patients (41%). Patients with elevated cTnI levels, compared with those with normal cTnI, were older (63 +/- 13 y vs 56 +/- 14 y, P =.032), had a higher incidence of males (78% vs 52%, P =.049) and positive ergonovine provocation tests (74% vs 30%, P <.0001), and tended to have a lower incidence of hypercholesterolemia (26% vs 48%, P =.088) and normal electrocardiograms (48% vs 70%, P =.078). Multivariate analysis showed that the variables independently associated with an elevated cTnI level included coronary vasospasm (odds ratio 2.41, 95% CI 1.48-3.18, P <.0001) and hypercholesterolemia (odds ratio 0.64, 95% CI 0.47-0.99, P =.049). Coronary vasospasm (positive ergonovine provocation test) could explain 74% of elevated cTnI levels in patients with insignificant coronary stenosis.

CONCLUSIONS

In patients with acute coronary syndrome with elevated cTnI and insignificant coronary artery disease, the possibility of coronary vasospasm as a cause of elevated cTnI should be considered.

Cardiopulmonary resuscitation during coronary vasospasm induced by tilt table testing

A 65-year-old man presented to our institution with recurrent episodes of early morning chest discomfort and near syncope. An ergonovine provocation test documented a diagnosis of coronary vasospastic angina. Using our investigation of the syncope, a head-up tilt table test provoked a severe episode of coronary vasospasm that resulted in a life-threatening cardiac event. The present case reminds us that an elevation of ST segments on the electrocardiogram during tilt testing should be promptly managed as an attack of coronary vasospasm.

Arrhythmic cardiac arrest due to isolated coronary artery spasm: long-term outcome of seven resuscitated patients

OBJECTIVES

Our aim was to look at the clinical features and long-term follow-up of seven patients without coronary artery disease, who had a history of life-threatening ventricular arrhythmias due to coronary spasm.

BACKGROUND

Arrhythmic cardiac arrest due to isolated coronary spasm is rare, and there is limited information on the patients affected by this entity alone.

METHODS

The seven patients were recruited retrospectively from a cohort of survivors of cardiac arrest. None had a history of angina pectoris, structural heart disease or significantly narrowed coronary segments. All had a positive ergonovine provocation test result.

RESULTS

The patients' mean age was 44 years; three were male and four female. All were habitual cigarette smokers. No arrhythmias were induced on programmed ventricular stimulation; corrected QT interval (QTc) and corrected JT interval (JTc) dispersion were within normal ranges. After the ergonovine provocation test, treatment with calcium channel blocking agents (diltiazem, verapamil, nifedipine or amlodipine) was initiated at a dose determined by titration until a negative test result was obtained. At a mean follow-up interval of 58 months for the total group, six patients remained free of symptoms, whereas the one patient who did not stop smoking had a new cardiac arrest despite treatment for coronary spasm.

CONCLUSIONS

A favorable long-term outcome may be expected in survivors of cardiac arrest due to coronary spasm, in the absence of significant coronary artery disease. Calcium channel blockers are the most appropriate therapy in these patients. These observations provide further evidence for the role of silent ischemia in cardiovascular death.