Wandering coronary stenoses: Adrenaline‐induced coronary artery spasm in a patient resuscitated from cardiac arrest

Abstract

A 68-year-old ex-smoker man with history of allergy, presented to the emergency department with progressive dyspnea one hour following self-medication with aspirin for troublesome headache. Examination revealed diffuse sibilant rhonchi over both lungs. Electrocardiogram showed signs of ischemia. In the intensive care unit, he received bronchodilators, nitroglycerin, and aspirin. Bronchospasm increased, and then the patient was shocked, and developed cardiac arrest. After resuscitation, he was kept on mechanical ventilation and adrenaline infusion. He was scheduled for coronary angiography. The left system demonstrated stenosis of the mid-segment of the left anterior descending artery (LAD), which was totally occluded distally, stenosis of the left circumflex (LCx) with a mild plaque in its marginal branch. The right system demonstrated stenosis of the mid-segment of the right coronary artery (RCA), with diffusely diseased posterior descending artery (PDA) and posterolateral left ventricular branch (PLLV). Successful direct stenting was performed to the RCA. Angiography demonstrated worsening of the distal stenosis in the PLLV and complete occlusion of the PDA. Balloon dilatation of the PLLV was adequate, but dilatation of the PDA failed. Repeat angiography of the left system revealed an occluded LCx with critical stenosis of its marginal branch; nevertheless, the LAD was as before. Balloon dilatation of the distal LAD was attempted without improvement, yet, angiography therein, demonstrated "migration" of the stenoses in the LCx. The procedure was halted, adrenaline infusion discontinued, and an intra-aortic balloon pump inserted. The patient was discharged one day later. Follow-up angiography 6 months later demonstrated mild atherosclerotic coronary irregularities.

Peri-operative cardiac arrest and resuscitation

“…those with severe hypovolemia or those experiencing coronary artery spasm while receiving adrenaline for hemodynamic support). 14 Also, the recommendation to use resuscitative endovascular balloon occlusion (REBOA) in exsanguinating trauma patients who are in cardiac arrest or peri-arrest was based on retrospective studies that did not establish the complete picture. 6 While REBOA is effective at creating temporary control of bleeding and increasing afterload, it induces physiologic derangements and creates an abnormal physiological state in which a portion of the body undergoes profound ischaemia (and later reperfusion).…”

“…Some patients may not tolerate the drug (e.g. those with severe hypovolemia or those experiencing coronary artery spasm while receiving adrenaline for hemodynamic support) 14 . Also, the recommendation to use resuscitative endovascular balloon occlusion (REBOA) in exsanguinating trauma patients who are in cardiac arrest or peri-arrest was based on retrospective studies that did not establish the complete picture 6 .…”

Contribution of Catecholamine Reactive Intermediates and Oxidative Stress to the Pathologic Features of Heart Diseases

“…Special focus will be given to the pathologies or situations where high mortality or morbidity is reported, or for those where a close connection between catecholamines and the disease is mechanistically relevant. 22,[26][27][28][29][30][31][32][33][34][35]. Some of these manifestations occurred in patients even after using the therapeutically recommended doses of ADR.…”