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Page 1: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

RCA Spasm and VFa case report

Qi Zhang, MD Rui Jin Hospital

Shanghai Jiao Tong University School of Medicine

Page 2: RCA Spasm and VF a 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

Page 3: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

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.

Page 4: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

Baseline EKG after AdmissionAugust 11, 2009

Page 5: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

Hospital EKG Recording during VT and after

Resuscitation

Page 6: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

Coronary Angiogram 26h after admission

Page 7: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

What we do…

• IV. GP IIb/IIIa inhibitor (tirofiban)

• Change to 6 JR 3.5 Guiding Catheter

• Preparing to perform PCI to RCA…

Page 8: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

With Guiding Catheter

Page 9: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

RCA AngiogramComparison

1st with diagnositc catheter 2nd with guiding catheter

Page 10: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

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…

Page 11: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

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.

Page 12: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

CAG @ day 12

Page 13: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

RCA Angiogram Replay

1st 2nd 3rd

Page 14: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

PCI for LAD

6F JL 4.0 Guiding

Runthrough wire

2.0x20mm balloon

3.5x13mm F2 stent

3.5x10mm balloon

Page 15: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

Final Results

Page 16: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

EKG after PCIAugust 24, 2009

Page 17: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

Discharge Management

• Discharged on August 25, 2009

• On Medications: ASA, Clopidogrel,

Atorvastatin, Diltiazem, Nitrates.

• Intensive clinical follow-up, no MACE occurred.

Page 18: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

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

Page 19: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

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.

Page 20: RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine.

Thanks


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