A most unusual acute coronary syndrome

Abstract

A 60-year-old man with a seven-year history of coronary artery disease was admitted for suspected unstable angina. He was well until two weeks previously, when he experienced several episodes of squeezing chest pain while at rest, lasting 5 min to 15 min, accompanied by dyspnea and sweating. Episodes were relieved by sublingual nitroglycerine. In the previous month, the patient had also noted progressive dyspnea on light exertion and new-onset nocturnal dyspnea, with recent episodes of flushing and diarrhea. He had unaccountably lost 22.7 kg in the preceding four months. Night sweats and fever were absent. Recently, furosemide 40 mg had been added to control new-onset lower limb edema. Other daily medications were acetylsalicylic acid 81 mg, valsartan 80 mg and lovastatin 20 mg.In the emergency room, the physical examination showed a mildly obese man without distress. Central venous pressure was elevated with V waves. A grade II/VI holosystolic regurgitant murmur was heard at the left and right sternal borders. Lung auscultation was normal, and a 2 cm pitting edema was noted at the ankles with stasis dermatitis. The electrocardiogram (ECG) was normal and cardiac troponin was negative. The patient was admitted with a diagnosis of acute coronary syndrome. The patient was started on heparin, nitrates and a betablocker. Echocardiography showed normal left ventricular systolic function with grade 2 mitral and grade 3 tricuspid regurgitation. The sonographer also reported abnormal hepatic lesions compatible with liver metastases.During his hospital stay, the patient presented with several episodes of chest pain at rest. The ECG showed a junctional rhythm with ST segment elevation in the inferior leads (II, III and aVF) and ST segment depression in the other leads ( Figure 1). Coronary angiography showed diffuse disease with 70% stenosis in the mid segment of the left anterior descending coronary artery and a 50% stenosis on the second diagonal CASE REPORT ©2006 Pulsus Group Inc. All rights reserved C Bourgault, S Bergeron, P Bogaty, P Poirier. A most unusual acute coronary syndrome. Can J Cardiol 2006;22(5):429-432.A 60-year-old man, known for stable coronary artery disease, was admitted for suspected unstable angina. In the previous month, the patient presented with progressive dyspnea on light exertion. In the preceding four months, he had experience occasional episodes of flushing and diarrhea, and had inexplicably lost 22.7 kg. Night sweats and fever were absent. ST segment elevation in the inferior leads and ST segment depression in the precordial leads were documented during an episode of chest pain. The coronary angiogram showed diffuse disease with 70% stenosis of the left anterior descending coronary artery and 50% stenosis on the second diagonal (D 2 ). An echocardiogram showed a patent foramen ovale. Balloon angioplasty and stenting were performed on the two lesions. Two days later, prolonged chest pain recurred. Cardiac catheterization was repeated and showed occlusive thrombus within the stent on the D 2 ...

Carcinoid Heart Disease: Review of Current Knowledge

“…Coronary artery vasospasm is also associated with carcinoid HD, 27,28 usually in patients who have nonocclusive coronary artery disease. [27][28][29] Depending on endothelial conditions, serotonin can stimulate vasodilatory or constrictive responses. Serotonin can cause vasoconstriction in diseased endothelium (such as in patients with atherosclerotic disease) because of the predominance of vasoconstriction-provoking 5-hydroxytryptamine 2 (5-HT 2 ) receptors and the loss of 5-HT 1 receptors that mediate vasodilation.…”

“…[28][29][30][31][32][33] In addition, serotonin sometimes reaches the coronary circulation by means of shunting through a patent foramen ovale; as a known platelet activator, it might also contribute to stent thrombosis. 29,34 Possible coronary vasospasm should be considered when patients present with acute coronary syndrome and a history of carcinoid disease. Therapeutic decisions include whether to use vasodilators such as calcium channel blockers, serotonin antagonists, or somatostatin analogues.…”

Fatal Systemic Vasoconstriction in a Case of Metastatic Small-Intestinal NET

“…Commonly, hypotension is the expected hemodynamic change; however a small group of carcinoid patients experiences hypertension during carcinoid crisis [ 14 , 15 ]. The occurrence of localized or generalized vasospasms associated with NETs has been described in case reports only [ 16 – 18 ]; see also Table 2 .…”

Tricuspid Valve Regurgitation as a Presenting Symptom of Metastasized Carcinoid Tumor

“…The event in our patient, noticed by marked ECG findings, seems to be rare, with only two reports describing ECG changes in relation to serotonin-producing carcinoid tumors [9, 10]. It is believed that serotonin may affect coronary spasms, mimicking acute coronary syndrome with typical ECG changes, which may even lead to coronary stent placement and balloon dilatation.…”