Severe vasospastic angina complicated by multiple pulseless electrical activity arrests

摘要

In May, 2012, a 46-year-old woman reported chest pain before having an out-of-hospital cardiac arrest. Paramedics successfully resuscitated her. The pre-arrest rhythm strip showed a sinus tachycardia only. A 12-h troponin I was raised at 5.9 ug/L (normal values 0-0.04 ug/L) A year earlier, she had been admitted with a similar history of chest pain, which had developed after taking sumatriptan for a migraine. A 12-lead electrocardiograph (ECG) showed transient inferior and lateral ST elevation. A 12-h troponin was negative. At this time, coronary angiography showed a normal left coronary system and a dominant right coronary artery, with minor ostial spasm and slow flow. A bubble study was negative for right to left shunting. She was diagnosed with vasospastic angina and started oral diltiazem. On advice, she stopped smoking and sumatriptan was discontinued. She continued to have occasional episodes of chest pain responsive to sublingual glycerol trinitrate. At the time of her cardiac arrest, her regular medications were oral diltiazem, nicorandil, lansoprazole, and a beclo-metasone inhaler. In the 48 h after the cardiac arrest she had five additional pulseless electrical activity (PEA) arrests while intubated and ventilated in the intensive care unit. These were characterised by transient ST elevation (figure) and progressive hypotension, culminating in loss of cardiac output. Each episode responded to about 15-25 min of resuscitation. In between episodes, left ventricular size and function was normal on echo-cardiography. Electrocardiography was unremarkable.