Anginal attack following a sodium bicarbonate and hydrocortisone injection

Area of Science:

• Cardiology
• Clinical Medicine
• Pharmacology

Background:

• Variant angina (Prinzmetal's angina) is characterized by myocardial ischemia due to transient coronary artery vasospasm.
• Medications and physiological changes can precipitate or unmask underlying coronary artery spasm.

Observation:

• A 73-year-old man with variant angina presented with chest pain and shock post-injection of sodium bicarbonate and hydrocortisone.
• Electrocardiogram (ECG) showed transient ST elevation, resolving within 10 minutes.
• Coronary angiography revealed no significant coronary stenosis initially.

Findings:

• Ergonovine provocative testing one month later induced coronary artery spasms in specific segments (4 and 13), accompanied by ischemic ECG changes.
• The anginal episode was hypothesized to be caused by coronary artery spasm, potentially triggered by an allergic reaction to hydrocortisone or serum alkalosis from sodium bicarbonate, possibly exacerbated by hyperventilation.

Implications:

• This case highlights the potential for iatrogenic triggers of coronary artery spasm in susceptible individuals.
• It underscores the importance of considering non-atherosclerotic causes of acute coronary syndromes.
• Diagnostic protocols for variant angina may need to account for medication-induced or metabolic triggers.