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RCA Spasm and VFa case report
Qi Zhang, MD Rui Jin Hospital
Shanghai Jiao Tong University School of Medicine
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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
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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.
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Baseline EKG after AdmissionAugust 11, 2009
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Hospital EKG Recording during VT and after
Resuscitation
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Coronary Angiogram 26h after admission
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What we do…
• IV. GP IIb/IIIa inhibitor (tirofiban)
• Change to 6 JR 3.5 Guiding Catheter
• Preparing to perform PCI to RCA…
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With Guiding Catheter
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RCA AngiogramComparison
1st with diagnositc catheter 2nd with guiding catheter
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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…
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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.
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CAG @ day 12
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RCA Angiogram Replay
1st 2nd 3rd
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PCI for LAD
6F JL 4.0 Guiding
Runthrough wire
2.0x20mm balloon
3.5x13mm F2 stent
3.5x10mm balloon
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Final Results
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EKG after PCIAugust 24, 2009
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Discharge Management
• Discharged on August 25, 2009
• On Medications: ASA, Clopidogrel,
Atorvastatin, Diltiazem, Nitrates.
• Intensive clinical follow-up, no MACE occurred.
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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
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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.
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Thanks