A case of coronary artery spasm caused by manipulation of the neck: heart rate variability analysis

A 66-year-old man with no history of ischemic heart disease underwent cervical lymph node dissection. General anesthesia was induced and maintained with remifentanil, along with propofol. With manipulation of the neck and a subcutaneous injection of lidocaine supplemented with adrenaline before the operation, a sudden decrease in blood pressure (BP) and elevation of the ST-T segment appeared on the monitoring electrocardiogram (ECG). Ephedrine, phenylephrine, adrenaline, and nitroglycerin were administered; however, the hypotension was sustained and the ECG abnormalities progressed, along with further elevation of the ST-T segment and a complete atrioventricular block. Following an injection of atropine, the changes in ECG and BP were attenuated. Heart rate variability (HRV) was analyzed using fully recorded monitor variables, and revealed an increase in the high-frequency domain at the time of the cervical manipulation, suggesting simultaneous vagal stimulation and coronary artery spasm. We concluded that the cervical manipulation had increased the vagal tone and we note that HRV analysis was useful to interpret this coronary event.