Atherothrombotic out-of hospital cardiac arrest: watch out for a second train

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiac Electrophysiology

Background:

• Coronary artery spasm can cause life-threatening cardiac events, including out-of-hospital cardiac arrest.
• Atherosclerotic plaque rupture is a common cause of acute coronary syndromes, but vasospasm should also be considered in unexplained cardiac events.
• Recurrent ventricular arrhythmias can occur even after initial treatment for acute coronary syndromes.

Observation:

• A 63-year-old male presented with out-of-hospital cardiac arrest, initially treated for atherosclerotic cap rupture in the left anterior descending artery.
• The patient subsequently developed recurrent ventricular arrhythmias and transient ST-segment elevation despite normal coronary angiography, suggesting an alternative diagnosis.

Findings:

• A methylergonovine provocative test revealed an occlusive right coronary artery spasm as the cause of recurrent events.
• Drug-eluting stent implantation in the right coronary artery effectively resolved the vasospasm and prevented further cardiac events.

Implications:

• This case highlights the importance of considering coronary artery spasm in patients with recurrent ventricular arrhythmias, even after initial treatment for atherosclerosis.
• Coronary artery spasm can mimic or coexist with atherosclerotic coronary artery disease, necessitating comprehensive diagnostic evaluation.
• Drug-eluting stent implantation can be a successful therapeutic strategy for managing refractory coronary artery spasm.