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ATYPICAL PRESENTATION OF DIFFUSE MULTIVESSEL CORONARY ARTERY SPASM
A688 JACC March 17, 2015 Volume 65, Issue 10S
FIT Clinical Decision Making Atypical Presentation of Diffuse Multivessel Coronary Artery Spasm Poster Contributions Poster Hall B1 Sunday, March 15, 2015, 9:45 a.m.-10:30 a.m. Session Title: FIT Clinical Decision Making: Ischemic Heart Disease Abstract Category: TCT@ACC-i2: Invasive Cardiovascular Angiography and Intervention Presentation Number: 1180-158 Authors: Amit Zachariah, Elsayed Abo-Salem, Timothy Smith, Tarek Helmy, University of Cincinnati, Cincinnati, OH, USA
Background: Coronary artery spasm (CAS) is characterized by transient periods of angina associated with ST-segment elevation on the electrocardiogram, generally occurring in the absence of obstructive coronary artery disease. Case: An 80-year-old African American female with a history of a drug eluting stent to the distal left anterior descending artery (LAD) six months ago presented with chest pain for one and a half hours. She had stable vitals, an unremarkable cardiac exam, mildly positive troponin and a negative urine drug screen. An electrocardiogram showed diffuse T wave inversions. Angiography showed a normal left coronary artery system with patent stent, however during the catheter exchange for engagement of right coronary artery (RCA), she became hypotensive to a systolic blood pressure of 60.
Decision Making: Telemetry revealed ST elevation in the inferolateral leads. The RCA was occluded and an ostial coronary dissection was considered, but the wire passed easily. Balloon angioplasty of the proximal vessel showed no change. An intra-aortic balloon pump was placed for hemodynamic support. Inadvertent thrombus injection was considered and a thrombectomy catheter was advanced over the wire with aspiration revealing no thrombus. We injected nitroglycerine into the RCA through the thrombectomy catheter’s side port to account for possible CAS resulting in opening of the vessel. Angiography of the left coronary system showed severe CAS of the LAD and the circumflex arteries that resolved with intracoronary nitroglycerine. Hemodynamics improved, a nitroglycerine drip was started and she was admitted to the cardiovascular intensive care unit. Two further episodes of transient chest pain and inferolateral ST elevation resolved with sublingual nitroglycerine. The balloon pump was removed and she was transitioned to isosorbide mononitrate and amlodipine without recurrence at two month follow-up.
Conclusion: This was a case of diffuse CAS causing cardiogenic shock in an elderly female. The thrombectomy catheter was a useful delivery device for intracoronary nitroglycerine which resolved the CAS. CAS should be considered in the differential for hypotension during angiography.
FIT Clinical Decision Making Atypical Presentation of Diffuse Multivessel Coronary Artery Spasm Poster Contributions Poster Hall B1 Sunday, March 15, 2015, 9:45 a.m.-10:30 a.m. Session Title: FIT Clinical Decision Making: Ischemic Heart Disease Abstract Category: TCT@ACC-i2: Invasive Cardiovascular Angiography and Intervention Presentation Number: 1180-158 Authors: Amit Zachariah, Elsayed Abo-Salem, Timothy Smith, Tarek Helmy, University of Cincinnati, Cincinnati, OH, USA
Background: Coronary artery spasm (CAS) is characterized by transient periods of angina associated with ST-segment elevation on the electrocardiogram, generally occurring in the absence of obstructive coronary artery disease. Case: An 80-year-old African American female with a history of a drug eluting stent to the distal left anterior descending artery (LAD) six months ago presented with chest pain for one and a half hours. She had stable vitals, an unremarkable cardiac exam, mildly positive troponin and a negative urine drug screen. An electrocardiogram showed diffuse T wave inversions. Angiography showed a normal left coronary artery system with patent stent, however during the catheter exchange for engagement of right coronary artery (RCA), she became hypotensive to a systolic blood pressure of 60.
Decision Making: Telemetry revealed ST elevation in the inferolateral leads. The RCA was occluded and an ostial coronary dissection was considered, but the wire passed easily. Balloon angioplasty of the proximal vessel showed no change. An intra-aortic balloon pump was placed for hemodynamic support. Inadvertent thrombus injection was considered and a thrombectomy catheter was advanced over the wire with aspiration revealing no thrombus. We injected nitroglycerine into the RCA through the thrombectomy catheter’s side port to account for possible CAS resulting in opening of the vessel. Angiography of the left coronary system showed severe CAS of the LAD and the circumflex arteries that resolved with intracoronary nitroglycerine. Hemodynamics improved, a nitroglycerine drip was started and she was admitted to the cardiovascular intensive care unit. Two further episodes of transient chest pain and inferolateral ST elevation resolved with sublingual nitroglycerine. The balloon pump was removed and she was transitioned to isosorbide mononitrate and amlodipine without recurrence at two month follow-up.
Conclusion: This was a case of diffuse CAS causing cardiogenic shock in an elderly female. The thrombectomy catheter was a useful delivery device for intracoronary nitroglycerine which resolved the CAS. CAS should be considered in the differential for hypotension during angiography.