The mechanism of dysrhythmias in variant angina pectoris: occlusive versus reperfusion

Thirty-six patients with variant angina pectoris (VAP) were analyzed to investigate whether the mechanism underlying dysrhythmia is related to coronary occlusion or reperfusion. Fifteen of the 36 patients demonstrated dysrhythmias (42%). Twelve of 15 patients (80%) experienced dysrhythmia prior to the acme of ST-segment elevation (occlusive dysrhythmia), and those of tachyarrhythmia type were characterized by the presence of ventricular premature beats initially isolated, increasing in frequency, and preceding the more malignant forms of dysrhythmias, such as ventricular tachycardia or ventricular fibrillation. The occlusive dysrhythmias included ventricular dysrhythmia (ventricular premature beats, ventricular tachycardia, slow ventricular tachycardia, ventricular fibrillation) in eight patients and conduction abnormalities (second- and third-degree AV block, left posterior fascicular block) in four patients. Thirteen episodes of VAP were fully recorded electrocardiographically. The average time to onset of dysrhythmia, after the beginning of ST-segment elevation, was 4.94 minutes +/- 1.52. The duration of the episodes without dysrhythmia was 0.86 minute +/- 0.53. The "reperfusion dysrhythmia" occurred in three patients (20%) and was characterized by the appearance of isolated couplets of ventricular premature beats, ventricular tachycardia, or ventricular fibrillation without prodromal ectopic activity. The dysrhythmia occurred in one patient during the resolution of ST-segment elevation and in two patients within seconds of ST-segment normalization. We conclude that the occlusive related dysrhythmias are the most important mechanism in VAP. They are dependent on the duration of the ischemic episode.