Management of cardiac arrest caused by coronary artery spasm: Epinephrine/adrenaline versus nitrates

ST segment depression and ventricular fibrillation in a dog after contrast agent administration

An 11-year-old Toy Poodle underwent a computed tomography examination with contrast (iohexol) enhancement under anesthesia. Heart rate and R-wave amplitude on electrocardiogram (ECG) increased 2.5 min after iohexol administration, and end-tidal carbon dioxide decreased to 12 mmHg. A progressive ST segment depression was observed on ECG. Subsequently, the ECG waveform changed to ventricular fibrillation. However, spontaneous circulation returned following cardiopulmonary resuscitation. Myocardial ischemia or anaphylactic shock was suspected in the dog, which explains the ST segment depression observed on ECG. When performing radiological examinations with a contrast agent, the ECG waveform changes, such as an increase in heart rate, R-wave amplitude, or ST segment depression, should be carefully monitored. This might enable early detection of cardiac dysfunction and the ensuing cardiac arrest in dogs.

Variant angina in chronic kidney disease: a case report of an unusual presentation of cardiac arrest following dialysis

Variant angina (VA) is described as a relatively benign syndrome of unprovoked chest pain and electrocardiographic (ECG) changes. Chronic kidney disease (CKD) may be associated with this syndrome. However, the incidence of severe manifestations of VA in this patient cohort with kidney disease has not been elucidated. Also, no description has been made of coronary vasospam in relation to dialysis sessions. Our patient, a young female with CKD, had an unusual history of angina following dialysis sessions and she suffered an acute coronary syndrome complicated by cardiac arrest. The diagnosis was made on the basis of her clinical features, dynamic ECG changes, and coronary angiogram findings, and the patient was managed medically. Severe manifestations of VA may occur in chronic kidney disease, and this should be kept in mind by the treating physician. The association of coronary vasospasm with dialysis needs further analysis.

An interesting implantable cardioverter defibrillator treatment for lethal ventricular arrhythmias caused by coronary artery spasm: A case report

RATIONALE

Coronary artery spasm (CAS) could cause serious lethal ventricular arrhythmias. While implantable cardioverter defibrillators (ICDs) have been recommend for secondary prevention of sudden cardiac death related to lethal ventricular arrhythmias. However, in resuscitated sudden cardiac death caused by CAS, the effect of ICD is still not well clear.

PATIENT CONCERNS

A 60-year-old male presented with 2 episodes of syncope. Coronary angiography showed normal coronary arteries. Twenty-four hour Holter electrocardiograms revealed that there were repeatedly transient marked ST segment elevation in the all leads except avR lead, junctional rhythm, and subsequently nonsustained ventricular tachycardia.

DIAGNOSES

Ischemic-induced lethal ventricular arrhythmias caused by CAS.

INTERVENTIONS

Both calcium channel blocker (diltiazem, 180 mg twice daily) and nitrate (isosorbide dinitrate 40 mg twice daily) were initially administrated, and ICD was subsequently implanted as a secondary prevention.

OUTCOMES

In the early stage of CAS, ICD therapy terminated the lethal ventricular arrhythmias. Conversely, after the administration of epinephrine, ICD therapy, even combined with external defibrillation, failed in resuscitating sudden cardiac death.

LESSONS

For the sudden cardiac death related to lethal ventricular arrhythmias caused by CAS, ICD therapy is an efficient secondary prevention base on administrating coronary vasodilators. Furthermore, administration of epinephrine should be avoided during cardiorespiratory resuscitation of sudden cardiac death caused by CAS.

Usefulness of Intracoronary Epinephrine in Severe Hypotension during Percutaneous Coronary Interventions

Background and Objectives

Life-threatening hypotension during percutaneous coronary interventions (PCI) is devastating for the patient and is associated with fatal adverse outcomes. The aim of our study was to assess the usefulness of intracoronary epinephrine in severe hypotension unresponsive to other measures during PCI.

Subjects and Methods

We analyzed the Pusan National University Yangsan hospital cardiac catheterization laboratory database to identify patients who underwent PCI from December 2008 to July 2012. The outcomes were changes of blood pressure (BP) and heart rate (HR) before and after intracoronary epinephrine and in-hospital mortality.

Results

A total of 30 patients who were initially stable and received intracoronary epinephrine for severe hypotension during PCI were included. Following administration of intracoronary epinephrine (dose 181±24.8 microgram), systolic and diastolic BP (from 53.8±13.0 mm Hg up to 112.8±21.2 mm Hg, from 35±7.6 mm Hg up to 70.6±12.7 mm Hg, respectively) and HR (from 39.4±5.1 beats/min up to 96.8±29.3 beats/min) were increased. Additionally, 21 patients (70%) showed hemodynamically acceptable responses to intracoronary epinephrine without the intraaortic balloon pump and temporary pacemaker during the PCI. In-hospital mortality was 17% (n=5).

Conclusion

Although our study was small, intracoronary epinephrine was found to be well tolerated and resulted in prompt and successful recovery from severe hypotension in most patients when other measures were ineffective. Intracoronary epinephrine could be a safe and useful measure in patients developing severe hypotension during PCI.