Brief Communication
 

Coronary Artery Spasm as a cause of chest pain and re-elevation of ST
segment and cardiogenic shock after PTCA
Rajeev Bhardwaj , Rajeev Marwah
Department of Cardiology Indira Gandhi Medical College, Shimla-171001.
Abstract

We describe a case that underwent successful PTCA in cardiogenic shock but after half an hour, again had severe chest pain with re-elevation of ST segment and was found to have coronary artery spasm as a cause of recurrence of symptoms.

Key words: Chest pain, coronary angiography, coronary artery spasm.

Introduction

Coronary artery spasm is a well known cause of chest pain and may present as transient ST segment elevation in ECG. It is also known to occur after percutaneous transluminal coronary angioplasty (PTCA) and after stent implantation in the cardiac catheterization laboratory(cath lab.). However it rarely causes homodynamic compromise after successful PTCA.Assessment of Mitral valve

Mitral valve renders itself to close scrutiny by TEE owing to its posterior location. It has been extensively studied using 3D echocardiography and new insights into the complex geometry and function of the mitral valve have emerged. The ability to obtain realistic "surgeon's views" (Figure 1) and perpendicular en-face cut-plane of the mitral valve orifice and volumetric analysis of regurgitant jets has revolutionized the planning and performance of mitral valve procedures. With increasing emphasis being placed on mitral valve repair and superior role of 3DE in guiding percutaneous mitral

Case:

        70 years male was admitted to the medicine department of our hospital on 8.6.07 with acute ST elevation inferior wall myocardial infarction(MI) with right ventricular infarction. He was started on medical therapy and was thrombolized with streptokinase. He continued to have chest pain and went into cardiogenic shock. On 9.6.07 he was referred to us due to ongoing chest pain and cardiogenic shock. His blood pressure(BP) was 80mm Hg(systolic) on dopamine infusion. He was shifted to cath. Lab after starting tirofiban infusion. He was put on intraaortic balloon pump(IABP). His coronary angiography(CAG) was done which showed 40% stenosis of left anterior descending artery(LAD) in proximal part, chronic total occlusion(CTO) of left circumflex(LCx) in proximal part and total occlusion of right coronary artery(RCA) in mid segment(Fig. 1). It was decided to attempt PTCA of RCA and leave LCx as such, as it had CTO.After opening of RCA lesion with balloon, RCA was found to have around 90% stenosis  in distal part(Fig.2). After balloon dilatation of distal lesion, both lesions were implanted with drug eluding stent with no residual stenosis(Fig. 3). Patient improved, with no chest pain now, BP came to 120mm Hg(systolic) and ST segment settled. After observing the patient in the lab for around 15 minutes, he was shifted to cardiac care unit with continuous ECG monitoring. After half an hour, patient complained severe chest pain.

 

His BP started falling and came to 60mm Hg, systolic, heart rate went up to 150/min and monitor showed marked elevation of ST segment in inferior leads. Patient was shifted to cath lab, suspecting acute stent closure. His check angio was done which showed severe spasm distal to distal stent(Fig 4). He was given intra coronary(I/C) nitroglycerine(NTG), and spasm disappeared but now the spasm appeared in between the two stents(Fig. 5). He was again given I/C NTG and the spasm disappeared. Patient was observed in the cath lab for 15 minutes and was then shifted to CCU on NTG infusion. He remained asymptomatic after that and was discharged after 3 days. He did not have any angina on follow up.

 
  Figure 1. Right coronary artery shows total occlusion of coronary artery in mid segment.  

Correspondence: Dr Rajeev Bhardwaj, House no 24, Block 3, US Club, Shimla-171001.
Email: rajeevbhardwaj_dr@yahoo.com
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Indian Heart J. 2009; 61:188-190
 
Coronary Artery Spasm
 
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Figure 2. 90% stenosis of Right coronary artery seen in distal part after PTCA of proximal lesion.
  
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Figure 3. Right coronary artery after PTCA and stenting of both lesions showing no residual stenosis.
 
 
 
 
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Figure 4. Coronary artery spasm beyond the distal stent.
 
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Figure 6. Relief of coronary artery spasm after intra coronary
nitroglycerine.

 

 
 
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Figure 5. Coronary artery spasm in between after intra coronary nitroglycerine, with relief of distal spasm.

DISCUSSION
Chest pain after successful PTCA is a common problem. Though it may be benign, it is disturbing to the patient, relatives and to the cardiologist. Such pain may be indicative of acute coronary artery occlusion, coronary artery spasm, or MI, but also may reflect local coronary artery trauma. Commonly, repeat CAG after PTCA in patients with chest pain demonstrates widely patent lesion, which suggests that pain was due to coronary artery spasm, coronary artery stretching or non cardiac cause. As reported by National
Heart, Lung& Blood Institute PTCA registry, 4.6% of patients with PTCA have coronary occlusion, 4.3% suffer MI and 4.2% have coronary spasm. There is some evidence that non ischemic chest pain after coronary intervention is more
Indian Heart J. 2009; 61:188-190
 
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common after stent placement as compared to plain PTCA (41% Vs 12%). This may be due to continuous stretching of arterial wall by stent as the elastic recoil occurring after PTCA is minimized1. Versaci et al found that chest pain with features similar to habitual angina occur in absence of instent stenosis in 1/3 of patients after stent implantation and appears to be associated with more intense coronary vaso reactivity, as evidenced by
ergonovine I/C injection2. Schuepp et al found that 32.5% patients experienced early chest pain after PTCA (within 16 hrs), new ECG changes
were detected in 2.5%. in patients with chest pain and those without, Creatine kinase CK-MB levels and Troponin I levels were higher than twice the upper limit of normal (43.6 Vs 11.0%)3. Kunz et al found that routine use of intravenous NTG after coronary stenting significantly reduced the occurrence of minor myocardial necrosis. However the incidence of post
procedural chest pain remained unchanged4. Mini et al found that post procedural chest pain (PPCP) is associated with similar short term outcome as no PPCP but has higher restenosis, perhaps mediated by deep vessel injury and so may identify patients at higher risk of restenosis5.
Non ischemic chest pain develops in about half of all patients

undergoing stent implantation and seem to be related to vessel overexpansion caused by stent in dilated vessel segment6. This patient was different in the sense that he developed chest pain after around half an hour of shifting from cath lab, pain was associated with ST elevation and marked fall in BP. Due to these features, acute stent thrombosis was the most likely diagnosis. However, he was found to have spasm distal to the
distal stent. After giving I/C NTG, this spasm disappeared but spasm appeared in between the two stents, which again disappeared in response to I/C NTG.
REFERENCES
1. Jeremias A, Kutscher S, Haude M, et al. Chest pain after coronary interventional
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2. Versaci F, Gaspardone A, Tomai F, et al. Chest pain and coronary stent implantation. Am J Cardiol 2002;28(5):500-504.
3. Schuepp M, Richenbacker P. Chest pain early after percutaneous coronary intervention: incidence and relation to ECG changes, cardiac enzymes and follow up. J. Invasive Cardiol 2001;13(3):211-216.
4. Kurz DJ, Naegeli B, Bartel O. A double blind, randomized study of the effect of immediate intravenous nitroglycerine on the incidence of post procedural chest and myocardial neirosis after elective conorary stenting . Am Heart J 2000;139:35-43.
5. Kini AZ, Lee P, Mitre CA, et al. Post procedural chest pain after coronary stenting:
implication clinical restenosis. J. Am Coll Cardiol 2003;41(1):33-38.
6. Jereman A, Kubcher S, Haunde M et al. Non ischemic chest pain induced by coronary intervention: a prospective study comparing coronary angioplasty and stent implantation. Circulation 1998;98(24):2656-2658.
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