A 75-year-old woman with chest pain and transient severe left ventricular systolic dysfunction
Introduction: Coronary spasm can cause myocardial ischemia and angina in both patients with and without obstructive coronary artery disease. However, provocation tests using intracoronary acetylcholine (ACh) have been rarely performed in the Western world. Case report: We report a case of a 75-year-...
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| Format: | Article |
| Language: | English |
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Elsevier
2015-10-01
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| Series: | Revista Portuguesa de Cardiologia |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S0870255115002140 |
| _version_ | 1828891441632378880 |
|---|---|
| author | Jennifer Mancio Daniel Caeiro Rita Faria Miguel Marques Sofia Bernardino Marco Oliveira Aníbal Albuquerque Vasco Gama Ribeiro |
| author_facet | Jennifer Mancio Daniel Caeiro Rita Faria Miguel Marques Sofia Bernardino Marco Oliveira Aníbal Albuquerque Vasco Gama Ribeiro |
| author_sort | Jennifer Mancio |
| collection | DOAJ |
| description | Introduction: Coronary spasm can cause myocardial ischemia and angina in both patients with and without obstructive coronary artery disease. However, provocation tests using intracoronary acetylcholine (ACh) have been rarely performed in the Western world. Case report: We report a case of a 75-year-old woman with a history of hypertension and a mechanical aortic prosthesis who presented in the emergency room with acute-onset chest pain, widespread ST-segment depression and severe left ventricular systolic dysfunction, with no signs of prosthesis dysfunction. Emergent coronary angiography excluded obstructive coronary artery disease. Pain relief and normalization of ST segment and systolic function occurred within six hours. The patient was treated for a possible thromboembolic myocardial infarction and was discharged home asymptomatic. Two weeks later, cardiac magnetic resonance was performed showing inferoseptal transmural infarct scar, inferior and inferolateral subendocardial infarct and mid-basal ischemia in the anterior and anterolateral walls. She was readmitted with recurrence of chest pain and it was decided to perform a provocation test with ACh. After injection of ACh into the left anterior descending artery, chest pain, ST-segment depression, blood flow impairment (TIMI 1) and transient grade 3 atrioventricular (AV) block occurred. Intracoronary administration of nitrates reversed the coronary spasm and AV conduction disturbances. Twenty minutes later, chest pain and ischemic ST changes recurred; there was no response to vasodilators and the patient developed cardiac arrest with pulseless electrical activity. Advanced life support was maintained for 32 minutes without return of spontaneous circulation. Conclusions: Provocation tests have a high sensitivity and specificity for the diagnosis of vasospastic angina. Although it is rare, these tests have the potential risk of irreversible spasm leading to arrhythmia and death. Resumo: Introdução: O espasmo coronário pode causar isquemia miocárdica e angina em doentes com e sem doença coronária obstrutiva. Contudo, os testes de provocação com administração intracoronária de acetilcolina (ACh) têm sido raramente usados no mundo ocidental. Descrição do caso: Mulher de 75 anos com hipertensão arterial e prótese mecânica aórtica admitida no serviço de urgência por dor torácica aguda, depressão generalizada do segmento ST e disfunção sistólica grave do ventrículo esquerdo sem evidência de disfunção protésica. Realizámos angiografia coronária emergente que excluiu doença coronária obstrutiva. Seis horas após admissão, a dor, as alterações de ST e a disfunção ventricular normalizaram. Foi tratado como possível enfarte do miocárdio tromboembólico e teve alta assintomática. Duas semanas após, realizámos ressonância magnética cardíaca que mostrou cicatriz de enfarte transmural inferoseptal e de enfarte subendocárdico inferior e inferolateral, e isquemia anterior e ântero-lateral. A doente foi readmitida pela mesma sintomatologia e decidimos realizar estudo de provocação com ACh. Após a injeção de ACh na artéria descendente anterior documentámos dor torácica, depressão do segmento-ST, compromisso do fluxo (TIMI 1) e bloqueio atrioventricular (AV) completo. A administração intracoronária de nitratos reverteu o espasmo coronário e a perturbação da condução AV. No entanto, 20 minutos depois, houve recorrência de dor e alterações de ST sem resposta aos vasodilatadores evoluindo a doente para atividade elétrica sem pulso. Mantivemos suporte avançado de vida durante 32 minutos sem recuperação da circulação espontânea. Conclusão: Os testes de provocação têm elevada sensibilidade e especificidade para o diagnóstico de angina vasospática. Apesar de raro, estes testes também podem levar ao espasmo coronário irreversível, arritmia e morte. Keywords: Chest pain, Acute heart failure, Vasospastic angina, Provocative test with acetylcholine, Palavras-chave: Dor torácica, Insuficiência cardíaca aguda, Angina vasospástica, Testes de provocação com acetilcolina |
| first_indexed | 2024-12-13T13:18:08Z |
| format | Article |
| id | doaj.art-3edb237beba645598596c4a84006de46 |
| institution | Directory Open Access Journal |
| issn | 0870-2551 |
| language | English |
| last_indexed | 2024-12-13T13:18:08Z |
| publishDate | 2015-10-01 |
| publisher | Elsevier |
| record_format | Article |
| series | Revista Portuguesa de Cardiologia |
| spelling | doaj.art-3edb237beba645598596c4a84006de462022-12-21T23:44:28ZengElsevierRevista Portuguesa de Cardiologia0870-25512015-10-013410621.e1621.e8A 75-year-old woman with chest pain and transient severe left ventricular systolic dysfunctionJennifer Mancio0Daniel Caeiro1Rita Faria2Miguel Marques3Sofia Bernardino4Marco Oliveira5Aníbal Albuquerque6Vasco Gama Ribeiro7Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, Portugal; Corresponding author.Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, PortugalDepartment of Cardiology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, PortugalDepartment of Medicine, Centro Hospitalar do Médio-Ave, Vila Nova de Gaia, PortugalDepartment of Medicine, Centro Hospitalar do Médio-Ave, Vila Nova de Gaia, PortugalDepartment of Cardiology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, PortugalDepartment of Cardiology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, PortugalDepartment of Cardiology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, PortugalIntroduction: Coronary spasm can cause myocardial ischemia and angina in both patients with and without obstructive coronary artery disease. However, provocation tests using intracoronary acetylcholine (ACh) have been rarely performed in the Western world. Case report: We report a case of a 75-year-old woman with a history of hypertension and a mechanical aortic prosthesis who presented in the emergency room with acute-onset chest pain, widespread ST-segment depression and severe left ventricular systolic dysfunction, with no signs of prosthesis dysfunction. Emergent coronary angiography excluded obstructive coronary artery disease. Pain relief and normalization of ST segment and systolic function occurred within six hours. The patient was treated for a possible thromboembolic myocardial infarction and was discharged home asymptomatic. Two weeks later, cardiac magnetic resonance was performed showing inferoseptal transmural infarct scar, inferior and inferolateral subendocardial infarct and mid-basal ischemia in the anterior and anterolateral walls. She was readmitted with recurrence of chest pain and it was decided to perform a provocation test with ACh. After injection of ACh into the left anterior descending artery, chest pain, ST-segment depression, blood flow impairment (TIMI 1) and transient grade 3 atrioventricular (AV) block occurred. Intracoronary administration of nitrates reversed the coronary spasm and AV conduction disturbances. Twenty minutes later, chest pain and ischemic ST changes recurred; there was no response to vasodilators and the patient developed cardiac arrest with pulseless electrical activity. Advanced life support was maintained for 32 minutes without return of spontaneous circulation. Conclusions: Provocation tests have a high sensitivity and specificity for the diagnosis of vasospastic angina. Although it is rare, these tests have the potential risk of irreversible spasm leading to arrhythmia and death. Resumo: Introdução: O espasmo coronário pode causar isquemia miocárdica e angina em doentes com e sem doença coronária obstrutiva. Contudo, os testes de provocação com administração intracoronária de acetilcolina (ACh) têm sido raramente usados no mundo ocidental. Descrição do caso: Mulher de 75 anos com hipertensão arterial e prótese mecânica aórtica admitida no serviço de urgência por dor torácica aguda, depressão generalizada do segmento ST e disfunção sistólica grave do ventrículo esquerdo sem evidência de disfunção protésica. Realizámos angiografia coronária emergente que excluiu doença coronária obstrutiva. Seis horas após admissão, a dor, as alterações de ST e a disfunção ventricular normalizaram. Foi tratado como possível enfarte do miocárdio tromboembólico e teve alta assintomática. Duas semanas após, realizámos ressonância magnética cardíaca que mostrou cicatriz de enfarte transmural inferoseptal e de enfarte subendocárdico inferior e inferolateral, e isquemia anterior e ântero-lateral. A doente foi readmitida pela mesma sintomatologia e decidimos realizar estudo de provocação com ACh. Após a injeção de ACh na artéria descendente anterior documentámos dor torácica, depressão do segmento-ST, compromisso do fluxo (TIMI 1) e bloqueio atrioventricular (AV) completo. A administração intracoronária de nitratos reverteu o espasmo coronário e a perturbação da condução AV. No entanto, 20 minutos depois, houve recorrência de dor e alterações de ST sem resposta aos vasodilatadores evoluindo a doente para atividade elétrica sem pulso. Mantivemos suporte avançado de vida durante 32 minutos sem recuperação da circulação espontânea. Conclusão: Os testes de provocação têm elevada sensibilidade e especificidade para o diagnóstico de angina vasospática. Apesar de raro, estes testes também podem levar ao espasmo coronário irreversível, arritmia e morte. Keywords: Chest pain, Acute heart failure, Vasospastic angina, Provocative test with acetylcholine, Palavras-chave: Dor torácica, Insuficiência cardíaca aguda, Angina vasospástica, Testes de provocação com acetilcolinahttp://www.sciencedirect.com/science/article/pii/S0870255115002140 |
| spellingShingle | Jennifer Mancio Daniel Caeiro Rita Faria Miguel Marques Sofia Bernardino Marco Oliveira Aníbal Albuquerque Vasco Gama Ribeiro A 75-year-old woman with chest pain and transient severe left ventricular systolic dysfunction Revista Portuguesa de Cardiologia |
| title | A 75-year-old woman with chest pain and transient severe left ventricular systolic dysfunction |
| title_full | A 75-year-old woman with chest pain and transient severe left ventricular systolic dysfunction |
| title_fullStr | A 75-year-old woman with chest pain and transient severe left ventricular systolic dysfunction |
| title_full_unstemmed | A 75-year-old woman with chest pain and transient severe left ventricular systolic dysfunction |
| title_short | A 75-year-old woman with chest pain and transient severe left ventricular systolic dysfunction |
| title_sort | 75 year old woman with chest pain and transient severe left ventricular systolic dysfunction |
| url | http://www.sciencedirect.com/science/article/pii/S0870255115002140 |
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