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A Young Woman With Refractory Vasospastic Angina

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her early 30s with a history of mild bronchial asthma and nasal polyps presented to the emergency department with chest pain, electrocardiographic ST elevation, and sudden cardiac arrest. Cardiopulmonary resuscitation was initiated and was followed with coronary angiography, which showed significant 3-vessel stenosis that completely resolved after nitroglycerin injection. The patient was diagnosed as having vasospastic angina (VA); diltiazem and glyceryl trinitrate were prescribed, and an implantable cardioverter-defibrillator (ICD) was implanted.

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Refractory coronary vasospasm in a patient with asthma

A. Start corticosteroid therapy

Several aspects of this patient’s management merit consideration. Sudden cardiac arrest can be a rare manifestation of coronary vasospasm. Fortunately, it was easy to diagnose in this patient because angiography was performed in the active phase of vasospasm. Long-acting nitrates and calcium channel blockers are the mainstays of treatment for coronary vasospasm. There are also other off-label medications such as statins, clonidine, and Rho-kinase inhibitors, which have been reported to be beneficial for vasospasm. Recent large-scale studies recommended ICD implantation in high-risk patients, especially for secondary prevention in those who survived sudden cardiac arrest.1 The arrhythmic episodes in this patient were asystole, not ventricular tachycardia or fibrillation. Possible explanation for inability to pace during one of the episodes of vasospasm is that diffuse spasm and subsequent myocardial stunning raised the pacing threshold and subsequent failure to capture. Routine threshold measurement in stable conditions would not reveal this problem. Her known response to nitroglycerin (Figure) led to treatment of her asystolic cardiac arrest with nitroglycerin, which had a dramatic response. The 2015 American Heart Association guideline for cardiopulmonary resuscitation recommends using nitroglycerine during the resuscitation of patients with cocaine-induced vasospasm2 but does not explicitly address patients with VA. Nevertheless nitroglycerin has been successfully used in the resuscitation of patients with VA,35 as was the case in this patient.

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Article Information

Corresponding Author: Ali Bozorgi, MD, Tehran Heart Center, Tehran University of Medical Sciences, North Kargar Street, Tehran, Iran (abozorgi@tums.ac.ir).

Published Online: August 14, 2019. doi:10.1001/jamacardio.2019.1667

Conflict of Interest Disclosures: None reported.

Additional Contributions: The authors thank Naser Saadat, MD, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran; Mahmonir Mohammadi, MD, Islamic Azad University, Tehran Medical Branch, Tehran, Iran; and Reza Rahmani, MD, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran, for their contribution in the treatment of the patient. No compensation was received.

References
1.
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2.
Neumar  RW, Shuster  M, Callaway  CW,  et al.  Part 1: executive summary: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.  Circulation. 2015;132(18)(suppl 2):S315-S367. doi:10.1161/CIR.0000000000000252PubMedGoogle ScholarCrossref
3.
Goto  K, Kurabayashi  M, Nakamura  T,  et al.  Aborted sudden cardiac death due to intractable ventricular fibrillation caused by coronary spasm refractory to implantable cardioverter defibrillator therapy.  Int J Cardiol. 2014;176(3):e133-e134. doi:10.1016/j.ijcard.2014.07.209PubMedGoogle ScholarCrossref
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Takagi  S, Goto  Y, Hirose  E,  et al.  Successful treatment of refractory vasospastic angina with corticosteroids: coronary arterial hyperactivity caused by local inflammation?  Circ J. 2004;68(1):17-22. doi:10.1253/circj.68.17PubMedGoogle ScholarCrossref
7.
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8.
Numasawa  Y, Motoda  H, Yamazaki  H, Kuno  T, Urushibara  K, Takahashi  T.  Successful treatment using corticosteroids in a patient with refractory vasospastic angina and bronchial asthma.  J Cardiol Cases. 2014;10(4):132-135. doi:10.1016/j.jccase.2014.06.008PubMedGoogle ScholarCrossref
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Kounis  NG, Zavras  GM.  Histamine-induced coronary artery spasm: the concept of allergic angina.  Br J Clin Pract. 1991;45(2):121-128.PubMedGoogle Scholar
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