Coronary Vasospasm Presenting As Prinzmetals Angina and Life
Threatening Brady-arrhythmia Independently at Different Times
Aijaz H Mansoor, Praveer Aggarwal, Sanjeev Bhardwaj, Vivek Tandon, Upendra Kaul

Department of Cardiology, Escorts heart institute and research centre,New Delhi

INTRODUCTION

‘Variant Angina’ was first described by Prinzmetal (1). It is characterized by episodes of chest pain at rest, associated with ST segmental elevation in the ECG. It mostly occurs in early morning hours, often in clusters, that last for 3 to 6 months, before abating. The underlying coronary anatomy is variable. A lower incidence of fixed atherosclerotic lesions has been noted in Japanese patients as compared to western patients.(2).

The mechanism is vasospasm is unclear. Factors implicated include endothelial dysfunction and activation of the autonomic nervous system.

We hereby present an unusual case of coronary vasospasm presenting as recurrent episodes of variant angina and recurrent symptomatic complete heart block and asystole occurring independent of each other at different times.

Case Report:

A 65 yrs old lady presented to us with a history of retrosternal chest pain and recurrent vomiting of 4 days duration. Four days before being seen by us she had episodes of unprovoked chest pain at rest, associated with vomiting and sweating, lasting 10-20 minutes. There was no concurrent dyspnea and the pain had no relation to posture or respiration.
She reported to her local hospital, where she was found to have severe hypertension (250/130mmhg.). Her initial ECG was regarded as normal  and spot trop T was negative.
 
Subsequent qualitative Trop T was found positive. She was admitted and managed as NSTEMI with accelerated hypertension. She received aspirin 150 mgs, clopidogrel 75 mgs, enoxaparin (1mg/kg twice a day), and nitroglycerine and atorvastatin 40 mgs. She became asymptomatic.  2 days later she had an episode of sudden dizziness in the early morning hours, while in the hospital. No chest pain was reported. The ECG recorded compete heart block with a wide QRS, slow escape rhythm (Fig 1 ).  She received atropine 2 ampoules I/V and sinus rhythm was restored. There were no accompanying ST T Changes.  Two days later, she had recurrence of chest heaviness with hypotension. She received I/V fluids, and was referred to our institute for further management.  Except for hypertension and history of cholecystectomy.10 years ago, her past history was unremarkable. She was a non smoker, with no family history of premature coronary artery disease or sudden cardiac death.

On examination, she was conscious, and comfortable. Pulse was 88 bpm and regular,  blood pressure was 150/70 mm hg .The clinical examination was unremarkable. ECG showed normal sinus rhythm with no ST –T changes.(fig 2).  The chest X ray was unremarkable. Echocardiography and Doppler examination revealed a normal LV, normal valves and no pericardial effusion. A Complete blood count, urine analysis, blood chemistries (Kidney function, liver function, blood sugar) and electrolytes were within normal limits. CK, CK–MB were in the normal range, but Trop T was elevated at 0.25 ng/ml. She was treated with intravenous nitroglycerine infusion, enoxaparin and statins. Non dihydropyridine calcium blockers ( diltizem) were initiated.

Fig 1. Patient in complete heart block (upper panel). Atropine I/V was administered as this ECG was being recorded. The precordial leads (lower panel) show atropine-induced sinus tachycardia.

Correspondence : Prof. Upendra Kaul, Executive Director, Department of Cardiology, Escorts Heart Institute & Research Centre, Okhla Road,
New Delhi – 110 025
Phone No. 91-11-26825000, Email : ukaul@vsnl.com

Discussion:

Variant angina is more frequently seen in East Asia as compared to West. 2-3 % of all patients undergoing coronary angiography for chest pain in the USA, are assigned a diagnosis of Varient angina, as against 20-30% in Japan (3) The condition is not common in our setting and incidence has not been reported, though there are anecdotal case reports.

It is mainly seen in younger females, who usually have no risk factors, except smoking. The chest pain is usually unprovoked. It can be precipitated by alcohol, nicotine, ergonovine, acetylcholine, hyperventilation, REM sleep, drinking iced drinks and atrial pacing.The attacks can be prevented or reverted by atropine,  alfa receptor blockers (Prazosin) and calcium channel blockers of both dihydropyridine (nifedipine) and non dihydropyridine class (verapamil and diltiazem).

Our patient had very unusual features besides being elderly without a past history.. The presentation had peculiarities that the chest pain and ST elevation in inferior leads was present without heart block. The heart block and asystole was seen in episodes of dizziness without ST changes in ECG or chest pain. The episodes of chest pain and symptomatic brady-arrhythmia occurred distinctly at different times while she was being closely monitored. Since she had no past history of syncope or history suggestive of brady-arrhythmias and the documented complete heart block and asystole occurred in time sequence of variant angina, it is presumed that the underlying etiology is the same. The electrophysiologic study done during the admission was normal indicating no underlying occult conduction disorder.

This dual mode of presentation is very unusual and to the best of our knowledge not reported earlier. It is likely that different segments of coronary arteries were involved in t spasm at different times. The complete heart block and asystole could have resulted from a spasm of the distal right coronary artery probably AV nodal branch at a time when the proximal vessels did not have a flow limiting spasm.

In untreated patients, during pain and ST elevation, ventricular arrhythmias pose a high risk pf SCD. In one study, 42% of patients experienced serious ventricular arrhythmias during ST elevation.(4) The risk is especially high in mutli-vessel vasospasm. Cardiac arrhythmias, both tachy-arrhythmias (during anterior ST segment elevation) and brady arrhythmias (during inferior ST segment elevation) have been reported during episodes of chest pain (5).