Acute Heart Failure Triggered by Coronary Spasm With Transient Left Ventricular Dysfunction

Abstract

SummaryCoronary spasm is abnormal contraction of an epicardial coronary artery resulting in myocardial ischemia. Coronary spasm induces not only depressed myocardial contractility, but also incomplete myocardial relaxation, which leads to elevated ventricular filling pressure. We herein report the case of a 55-year-old woman who had repeated acute heart failure caused by coronary spasm. Acetylcholine provocation test with simultaneous right heart catheterization was useful for the diagnosis of elevated ventricular filling pressure as well as coronary artery spasm. We should add coronary spasm to a differential diagnosis for repeated acute heart failure. (Int Heart J 2017; 58: 286-289) Key words: Coronary spastic angina, Acetylcholine provocation test, Right heart catheterization C oronary spasm is defined as abnormal contraction of an epicardial coronary artery resulting in myocardial ischemia. 1,2) The prevalence of coronary spasm is greater in Japan than in Western countries, because of genetic and environmental factors.1,2) Coronary spasm induces not only depressed myocardial contractility, but also incomplete myocardial relaxation, which leads to elevated ventricular filling pressure.1) We herein report a case of repeated acute heart failure caused by coronary spasm, which was diagnosed by acetylcholine provocation test with simultaneous right heart catheterization. Case ReportA 55-year-old Japanese woman was admitted to our hospital with acute heart failure accompanied by CO 2 narcosis. Her blood pressure was 154/92 mmHg and her heart rate was 111 beats/min on admission. Her arterial blood gas analysis showed a pH of 6.83, pCO 2 of 117.0 mmHg, and pO 2 of 98.3 mmHg at a fraction of inspired oxygen of 70% with non-invasive positive pressure ventilation on admission. Chest X-rays showed pulmonary edema (Figure 1), an electrocardiogram (ECG) showed poor R progression in leads V1-V3 (Figure 2), and echocardiography showed diffuse severe hypokinesis with a global left ventricular ejection fraction (LVEF) of 35%. Serum creatine kinase (CK) and serum creatine kinase MB isoenzyme (CK-MB) levels were 347 IU/L and 38 IU/L, respectively. The brain natriuretic peptide level was 450 pg/mL. Although she had no risk factors for coronary artery disease except age and current smoking, she had a history of 2 emergent admissions in 4 months: the first one at another hospital and the second one at our hospital. In the first admission, she had acute respiratory failure accompanied by CO 2 narcosis, which needed mechanical ventilation. Neither echocardiography nor coronary angiography (CAG) was performed during the first admission. Although the cause of her acute respiratory failure was not elucidated, the tentative diagnosis at the hospital was acute exacerbation of bronchial asthma. In the second admission, she had acute decompensated heart failure and was admitted to our hospital. Although blood analysis showed an increased CK level (5234 IU/L), the CK-MB level (78 IU/L) did not reach 10% of the CK level. ECG showed negati...

Acute Heart Failure Due to Multi-vessel Coronary Spasm

“…However, what differentiates this case from others ( 4 - 8 ) is the LVEF at the onset of HF. While other reports have described cases of HFrEF ( 4 - 8 ), this patient had a preserved LVEF, and detailed echocardiography performed during the stable period after hospitalization (day 5) did not show a typical HFpEF image. The elevation of the NT-proBNP levels in this case was not high, suggesting that this case corresponded to one of mild HF.…”

“…It has been widely accepted that coronary spasm is the pathogenesis of not only rest angina but also other types of coronary artery disease (CAD), including exertional angina, acute coronary syndrome, and ischemic sudden death (3). Consequently, coronary spasm is considered a possible cause of heart failure (HF) (4)(5)(6)(7)(8). In such reports (4)(5)(6)(7)(8), coronary spasm was associated with the presence of HF with a reduced ejection fraction (HFrEF) or transient left ventricular (LV) dysfunction.…”

“…Consequently, coronary spasm is considered a possible cause of heart failure (HF) (4)(5)(6)(7)(8). In such reports (4)(5)(6)(7)(8), coronary spasm was associated with the presence of HF with a reduced ejection fraction (HFrEF) or transient left ventricular (LV) dysfunction.…”