Europace Advance Access originally published online on May 21, 2007
Europace 2007 9(8):568-570; doi:10.1093/europace/eum087
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SYNCOPE
Coronary spasm: a case of transient ST elevation and syncopal ventricular tachycardia without angina
Dipartimento di Cardiologia, Policlinico Tor Vergata, Viale Oxford 81, Rome 00133, Italy
Manuscript submitted 20 October 2006. Accepted after revision 9 April 2007.
* Correspondence author: Viale di Villa Massimo 37, Rome 00161, Italy. Tel: +44 7936695891; fax: +39 0620900382. E-mail address: mark_m_gallagher{at}hotmail.com
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Abstract |
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We report the case of a 60-year-old male with recurrent pre-syncope, referred with a provisional diagnosis of carotid sinus syndrome on the basis of a 4 s asystolic pause following carotid sinus massage. On repeat Holter monitoring there was ST-segment elevation followed by episodes of polymorphic ventricular tachycardia during a mild episode of pre-syncope. Coronary angiography showed mild right coronary artery irregularity without significant stenosis. An automatic cardioverter defibrillator was implanted and high dose combined vasodilator therapy was commenced. At follow-up 18 months after implantation, the device has recorded no episode of tachycardia and the patient reports no recurrence of symptoms.
Key Words: Coronary spasm, Sudden death, Ventricular tachycardia, Ventricular fibrillation, Syncope, Carotid sinus syndrome
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Introduction |
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Prinzmetal or variant angina is an unusual syndrome of cardiac pain secondary to myocardial ischemia that occurs almost exclusively at rest, is not usually precipitated by physical exertion or emotional stress, and is associated with ST-segment elevation.1
The syndrome is associated with ventricular tachycardia and fibrillation.2 Patients with variant angina differ from those with typical angina in that traditional risk factors for atherosclerosis are often absent. |
Case report |
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A 60-year-old man underwent investigation of recurrent episodes of pre-syncope and one episode of syncope. Clinical examination and initial investigations were normal. The 12-lead ECG showed mild first degree AV block and right bundle branch block. Echocardiogram, chest X-ray and routine biochemical and haematological analyses were normal. No symptoms occurred during the initial Holter recording which was normal.
Carotid sinus massage, performed at a local referral centre, produced sinus bradycardia and transient atrio-ventricular block, with a pause of 4 s. Pre-syncope similar to the patient's spontaneous symptoms occurred in association with this pause. The patient was referred to us with view to pacemaker implantation.
While awaiting admission to our centre, a repeat 24 h ambulatory ECG was performed by the referring cardiologist. The only available Holter monitor was a 12-lead system. On this occasion, episodes of mild but otherwise typical symptoms occurred during the period of monitoring. These symptoms corresponded to episodes of fast polymorphic ventricular tachycardia (Figure 1). Each episode was preceded by ST-segment elevation in leads II, III, and aVF with reciprocal ST-segment depression in the anterior leads (Figure 2). All episodes of ventricular tachycardia occurred during the resolution of a period of ST-segment elevation of at least 30 s duration.
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Coronary angiography demonstrated an angiographically normal left coronary system, with irregularity without significant stenosis throughout the proximal part of a dominant right coronary artery. Combined vasodilator therapy with diltiazem and nitrates was commenced, and the patient underwent implantation of a dual-chamber defibrillator. At follow-up 18 months after implantation, the device has recorded no episode of tachycardia and the patient reports no recurrence of symptoms.
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Discussion |
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The symptoms of variant angina are similar to those of classical angina but occur without provocation and may be accompanied by syncope. When this is present, syncope is typically associated with inferior ST-segment elevation and either AV block or ventricular tachyarrhythmias.3
–5 Ventricular arrhythmias tend to occur during the reperfusion phase of the vasospastic episode rather than at the time of maximum ischemia.6
The treatment of vasospastic angina is based on non-specific vasodilators, particularly the non-dihydropyrridine calcium channel antagonists and the nitrates. Coronary stenting is helpful in patients with discrete proximal fixed obstructive lesions7 and may be indicated in patients with clinically severe, angiographically documented spasm refractory to aggressive pharmacologic management.8
Our patient showed none of the recognised indications for coronary stenting, but posed a particular challenge because of the aggressive nature of the ventricular arrhythmias documented and because of the lack of anginal symptoms. The absence of such symptoms denied us any reliable guide to the efficacy of vasodilator therapy in reducing the risk of sudden death. Although unselected patients with variant angina have a reasonable prognosis with 89–97% survival at 5 years,9 the risk of sudden death is high in patients who exhibit serious arrhythmias during episodes of chest pain.10
The positive response to carotid sinus massage in our patient, and the resulting decision to implant a pacemaker illustrate the hazards of reliance on this test. But for the occurrence of an event during repetition of an ambulatory ECG, the patient would have undergone implantation of a dual chamber pacemaker and no other therapy. Asystole for more than 5 s can occur in response to carotid sinus massage in healthy persons.11,12 Implantation of a pacemaker solely on the basis of this test exposes some patients to the hazards and inconvenience of an unnecessary procedure. As our case illustrates, it may also expose some to the greater danger of missing an important diagnosis.
Conflict of interest: None declared
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References |
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[1] Prinzmetal M, Kennamer R, Merliss R, Wanda T, Bor N. Angina pectoris. I. A variant form of angina pectoris: preliminary report. Am J Med (1959) 27:375–88.[CrossRef][Web of Science][Medline]
[2] Tsurukawa T, Kawabata K, Miyahara K, Kawano R, Sohara H, Amitani S, et al. Sudden death during Holter electrocardiogram monitoring in a patient with variant angina. Intern Med (1996) 35:966–9.[Web of Science][Medline]
[3] Onaka H, Hirota Y, Shimada S, Kita Y, Sakai Y, Kawakami Y, et al. 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.[Abstract]
[4] Unverdorben M, Haag M, Fuerste T, Weber H, Vallbracht C. Vasospasm in smooth coronary arteries as a cause of asystole and syncope. Catheterization and Cardiovascular Diagnosis (1997) 41:430–4.[CrossRef][Web of Science][Medline]
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[6] Myerburg RJ, Kessler KM, Mallon SM, Cox MM, deMarchena E, Interian A, et al. Life -threatening ventricular arrhythmias in patients with silent myocardial ischemia due to coronary–artery spasm. N Engl J Med (1992) 326:1451–5.[Abstract]
[7] Gaspardone A, Tomai F, Versaci F, Ghini AS, Polisca P, Crea F, et al. Coronary artery stent placement in patients with variant angina refractory to medical treatment. Am J Cardiol (1999) 84:96–8.[CrossRef][Web of Science][Medline]
[8] Khatri S, Webb JG, Carere RG, Dodek A. Stenting for coronary artery spasm. Catheter and Cardiovascular Interventions: Official Journal of the Society for Cardiac Angiography & Interventions (2002) 56:16–20.
[9] Yasue H, Takizawa A, Nagao M, Nishida S, Horie M, Kubota J, et al. Long term prognosis for patients with variant angina and influential factors. Circulation (1988) 78:1–9.
[10] Shimokawa H, Nagasawa K, Irie T, Egashira K, Sagara T, Kikuchi Y, et al. Clinical characteristics and long-term prognosis of patients with variant angina. A comparative study between western and Japanese populations. Int J Cardiol (1988) 18:331–49.[CrossRef][Web of Science][Medline]
[11] Jeffreys M, Wood DA, Lampe F, Walker F, Dewhurst G. The heart rate response to carotid artery massage in a sample of healthy elderly people. Pacing Clin Electrophysiol (1996) 19:1488–92.[CrossRef][Medline]
[12] Kerr SR, Pearce MS, Brayne C, Davis RJ, Kenny RA. Carotid sinus hypersensitivity in asymptomatic older persons: implications for diagnosis of syncope and falls. Arch Intern Med (2006) 166:515–20.
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