Recurrent cardiac arrest due to electro-mechanical dissociation in a patient with variant angina -- a case report

We present a case of a 44-year-old male with recurrent episodes of cardiac arrest in the course of Prinzmetal's angina. Episodes of variant angina can be life threatening due to episodes of advanced atrioventricular block, asystole, ventricular tachycardia or ventricular fibrillation. It has been suggested to implant an ICD in all patients with variant angina after cardiac arrest. This patient received an ICD, however, he died suddenly 6 months later. The possible mechanism of cardiac arrest was an electromechanical dissociation.     

Complications of variant angina: a case report

The case of a patient with Prinzmetal's angina causing syncope due to atrioventricular block, and later causing death, is presented. Electrocardiogram during the episodes demonstrate multiple coronary artery involvement. Detection and differential diagnosis of ST-segment elevation during paced rhythm is discussed.     

Three-vessel coronary artery spasm in a patient with variant angina and normal coronary arteries

Variant angina with two or more electrocardiographic or angiographic localizations has seldom been reported [1-4]. We present a case of variant angina pectoris and normal coronary arteries with three different and independent electrocardiographic localizations.     

Effort angina without coronary obstruction in a patient with Takayasu's aortitis: a case report

Angina occurring in patients with Takayasu's aortitis is attributed to the narrowing of the coronary ostium and/or aortic regurgitation. We treated a patient with Takayasu's aortitis with effort angina, in whom there was no obstruction of the ostium or aortic regurgitation. Treadmill exercise stress test revealed significant ST depression in leads V4-6, II, III and aVF with chest pain. Examinations of lactate in coronary sinus as well as arterial blood suggested the occurrence of myocardial ischemia during atrial pacing. The DPTI/TTI index was decreased and the left ventricular end-diastolic pressure was increased during angina. It is considered that the reduced coronary perfusion pressure resulted from a low diastolic aortic pressure and the elevated left ventricular end-diastolic pressure decreased the DPTI/TTI index and contributed to the development of subendocardial ischemia.     

Thromboembolism after cardiac surgery in a patient with cancer-related thrombosis and severe thrombocytopenia: A case report

Rationale:Patients with cancer have elevated risk of both venous thromboembolism and bleeding compared with patients without cancer due to cancer- and patient-specific factors. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult because management of cancer-associated thrombosis requires anticoagulation despite its known increased risks for bleeding. The adjustment of blood transfusion or cessation of anticoagulants can be a challenge in surgical diagnosis or treatment of cancer patients with such an imbalanced coagulate status.Patient concerns:A 45-year-old woman with no underlying disease was suspected of ovarian cancer and was awaiting diagnostic laparoscopic exploration surgery.Diagnoses:While waiting for the surgery, the patient developed chest pain and underwent stent insertion under diagnosis of myocardial infarction. Two weeks later, endocarditis developed, and replacement of the aortic valve and mitral valve was planned. In addition, the patient developed multiple thromboembolisms and was administered anticoagulants to eliminate vegetation of valves and multiple thromboses. Her blood test showed anemia (7.4 g/dL) and severe thrombocytopenia (24 × 10⁹/L).Interventions:The patient underwent double valve replacement.Outcomes:A color change of the left lower extremity was noted 5 hours after double valve replacement, and angiography was performed. Thrombectomy was performed under diagnosis of thrombosis in the left iliac artery. One month later, the patient underwent laparoscopic exploration surgery as scheduled.Lessons:This case will help establish the criteria of blood coagulation for surgical treatment of cancer patients with imbalanced clotting and bleeding.     

Prinzmetal's variant form of angina with arteriographic evidence of coronary arterial spasm

Spasm of the proximal right coronary artery was arteriographically demonstrated during an episode of chest pain in a patient with Prinzmetal's variant form of angina. A right aortocoronary saphenous vein bypass procedure was performed but, despite a patent graft, the angina recurred and the patient died. The only significant finding at autopsy was an eccentric atherosclerotic plaque that narrowed the right coronary artery by 75 percent at the site of the spasm. These findings support Prinzmetal's hypothesis that this variant form of angina is produced by spasm of a coronary artery with a seriously compromised lumen.     

Dynamic intercoronary collateral flow in a patient with variant angina and coronary artery spasm

Intermittent intercoronary collateral flow was observed in a patient with coronary vasospasm associated with variant angina. Collateral flow began almost immediately after total occlusion of the right coronary artery, but did not prevent pain or S-T segment elevation. Some collateral vessels may pre-exist ischemic conditions and flow across these channels may be immediately dependent on the pressure gradient across them.     

Congenital atresia of left main coronary artery: proposed mechanism for severe disabling angina in a patient with non-atherosclerotic single right coronary artery--a case report

A patient with progressive disabling angina was found to have a single right coronary artery with atresia of the left main coronary artery, and absence of any obstructive coronary disease. The patient required aortocoronary by-pass surgical reconstruction of a left main coronary artery to control her angina. Possible mechanisms for the development of her anginal pain are briefly discussed.     

Prinzmetal's variant angina associated with subarachnoid hemorrhage: A case report.

Prinzmetal's variant of angina occurred in a 48-year-old man who sustained two attacks of subarachnoid hemorrhage within 10 days. The first anginal pain started at the same time that the second cerebrovascular accident developed, but subsequent anginal episodes were not accompanied by other symptoms or signs that indicated new development of subarachnoid hemorrhage. Twelve days later, when nuchal rigidity was fairly improved, the episodes of chest pain ended. A vasospasm of the large coronary arteries--probably due to the derangement of the autonomic nervous system caused by subarachnoid hemorrhage--was presumed to contribute to the occurrence of the variant angina. Based on this case and on review of the literature, we propose that coronary arterial spasm is one of several causes of the cardiac changes seen in subarachnoid hemorrhage.     

Coronary arterial wall disruption and intramural hematoma in a patient with coronary spastic angina

Acute myocardial infarction is sometimes complicated in patients with coronary spastic angina. The mechanisms are known to be plaque rupture and thrombosis induced by spasm, and reduced coronary flow due to prolonged spasm. We describe the case of a 45-year-old woman with coronary spastic angina who had a complication of an acute myocardial infarction. A specimen obtained with thrombectomy was the disrupted coronary artery wall accompanied by massive intramural hemorrhage. The cause of the acute myocardial infarction was thought to be an embolism of the coronary arterial wall that was disrupted by spasm and intramural hemorrhage.     

Nocturnal angina: precipitating factors in patients with coronary artery disease and those with variant angina

Factors precipitating nocturnal myocardial ischaemia were investigated in 10 patients with frequent daytime and nocturnal angina pectoris. Eight patients had fixed obstructive coronary artery disease or a low exercise threshold or both before the onset of ischaemia. Two patients had variant angina with normal coronary arteries and negative exercise tests. During sleep the electrocardiogram, electroencephalogram, electro-oculogram, electromyogram, chest wall movements, nasal airflow, and oxygen saturation were continuously measured. Forty two episodes of transient ST segment depression were recorded in the eight patients with coronary artery disease and 26 episodes of ST segment depression and elevation in the two patients with variant angina and normal coronary arteries. All episodes of ST segment depression in the former group of patients were preceded by an increase in heart rate as a result of arousal and lightening of sleep, bodily movements, rapid eye movement sleep, or sleep apnoea (one episode). In contrast, in the variant angina group no increase in heart rate, arousal, or apnoea preceded 23 of the 26 episodes of ST segment change. Thus increase in myocardial oxygen demand was important in precipitating nocturnal angina in patients with coronary artery disease and reduced coronary reserve. In the patients with coronary spasm these factors did not often precede the onset of nocturnal myocardial ischaemia.     

Angiographic documented coronary arterial spasm in absence of critical coronary artery stenoses in a patient with variant angina episodes during exercise and dobutamine stress echocardiography

Dobutamine stress echocardiography is widely performed as a useful diagnostic tool in patients with known or suspected coronary artery disease. Dobutamine induced myocardial ischaemia is frequently associated with ST segment depression. ST segment elevation is uncommon and is almost always associated with prior myocardial infarction or transient total coronary occlusion. Dobutamine induced ST segment elevation in absence of significant coronary artery disease is a rare condition and is supposed to be a consequence of severe coronary artery spasm. The case of a 58 year old man with variant angina episodes at rest, during exercise test, and dobutamine stress echocardiography is reported, in whom coronary spasm without significant coronary artery stenoses was documented angiographically.


Keywords: coronary spasm; variant angina; Prinzmetal angina; dobutamine stress echocardiography; exercise test     

Refractory variant angina controlled with combined drug therapy in a patient with a single coronary artery

A young man with a single left coronary artery and refractory variant angina is described. Spontaneous coronary artery spasm developed during coronary arteriography at the site of a 50% fixed left anterior descending coronary artery stenosis. Frequent episodes of rest angina with transient ST segment elevation persisted in hospital in spite of treatment with three different calcium antagonist drugs. Symptoms disappeared only when the combination of nifedipine, diltiazem, isosorbide dinitrate, and nitroglycerin ointment were given. Ergonovine testing was used to objectively assess the response to treatment.