RCA Spasm and VFa case report
Qi Zhang, MD Rui Jin Hospital
Shanghai Jiao Tong University School of Medicine
Case information• Female, 61y
• Brief history: chest discomfort in 2 weeks, with occurrence of syncope in last 4 days (twice). VF occurred in ER, rescued by electronic shock. Admitted with diagnosis of ACS on August 11, 2009.
• Coronary risk factors: none
After Admission…• ACS regimen: ASA, Clopidogrel, Statins,
Isoket, Betaloc, LMWH, etc.• Lab findings: CK-MB 14.4ng/ml
(NR:0.3~4.0), TnI 1.69ng/ml (NR:<0.04) • LVEF: 0.51• She had re-occurrence of VF during
hospitalization, and rescued by electronic shock and CRP, followed by anti-arrhythmia therapy.
Baseline EKG after AdmissionAugust 11, 2009
Hospital EKG Recording during VT and after
Resuscitation
Coronary Angiogram 26h after admission
What we do…
• IV. GP IIb/IIIa inhibitor (tirofiban)
• Change to 6 JR 3.5 Guiding Catheter
• Preparing to perform PCI to RCA…
With Guiding Catheter
RCA AngiogramComparison
1st with diagnositc catheter 2nd with guiding catheter
What to do ?• What we did:• Stop the procedure…• Continuing with Tirofiban…• IV. Using Calcium Channel Antagonist
(Diltiazem 30mg q8h)• Increase the dosage of statin (atorvastain 80mg)• Add oral Nifedipine controlled-release tablet
(adalat 30mg/d)• Continue with ASA, Clopidogrel, LMWH,
Nitrates…
With Intensive Anti-Spasm and Statins Therapy
• The patient was stable in the following 10 days.
• At day 12 after admission, PCI for LAD was performed.
CAG @ day 12
RCA Angiogram Replay
1st 2nd 3rd
PCI for LAD
6F JL 4.0 Guiding
Runthrough wire
2.0x20mm balloon
3.5x13mm F2 stent
3.5x10mm balloon
Final Results
EKG after PCIAugust 24, 2009
Discharge Management
• Discharged on August 25, 2009
• On Medications: ASA, Clopidogrel,
Atorvastatin, Diltiazem, Nitrates.
• Intensive clinical follow-up, no MACE occurred.
Therapeutic Options in Coronary Spasm Cessation of smoking ObligatoryCalcium antagonists The most commonly used drugsLong-acting nitrates Alone, or in combination with calcium antagonistsMagnesium IV for acute therapy Oral supplementation for possible preventionStatins In addition to calcium antagonists To inhibit the RhoA-associated kinase pathwayPercutaneous interventions If refractory to medical therapy, stent implantation may be successfulCoronary bypass Success rate disputedImplantable defibrillator If life-threatening arrhythmias are documented
Stern S. et al. Circulation 2009;119:2531
Take - Home Messages• ACS/VF, coronary spasm may be the cause.• Anti-spasm medication and intensive statins
therapy should be considered in refractory ACS/VF patients.
• Early coronary invasive procedure should be performed in high-risk/electronic unstable ACS patients.
• Aggressive anti-arrhythmia devices/ICD should be avoided in those stable patients after revascularization and intensive medications.
Thanks