Diagnosis and management of out-of-hospital cardiac arrest secondary to coronary artery spasm
Introduction
Sudden cardiac death remains a serious clinical problem [1], [2]. Despite community and hospital-based interventions, pre-hospital mortality rates are still elevated and survival of hospitalized patients has not improved markedly in the past decades [3]. To improve the prognosis of out-of-hospital cardiac arrest (OHCA), strategies focused on out-of-hospital management, prevention and treatment of repeat arrhythmias and recognition of subjects at high risk for sudden cardiac death are warranted [4].
Coronary artery atherosclerosis is the most frequent cause of sudden cardiac death [5], [6] whereas variant angina is usually reported as a rare cause of sudden death [7], [8], [9]. However, its rate is probably underestimated in studies on sudden death since provocation tests for coronary artery spasm are not performed on a routine basis in survivors with no obvious cardiac or non cardiac cause of arrest. Prompt diagnosis and appropriate management of coronary artery spasm in such patients could be clinically relevant since treatment with calcium channel antagonists may be associated with a good long term prognosis [10].
Since our previous study on the rate of coronary occlusion and unstable coronary artery lesions as causes of OHCA [6], management of OHCA at our institution includes immediate coronary angiography on admission in survivors.
In patients with no or minimal coronary artery stenosis, a second angiography with provocation test was performed at 1 month. The rate, immediate and long-term clinical characteristics of coronary artery spasm as a cause of cardiac arrest were then determined.
Section snippets
Material and methods
In Paris the management of OHCA involves emergency units based in five hospitals in the city and one dispatching centre with two physicians. Each emergency unit is equipped with ambulances with resuscitation devices staffed by physicians. Four units participated in the study, covering a population of approximately 5 million during the day and 2.5 million at night. In suspected cases of sudden cardiac arrest, the closest emergency unit is dispatched to the scene, and resuscitation is initiated
Results
From September 1994 to 2000 four emergency units responded to 4001 cases of OHCA (Fig. 1). Cardiopulmonary resuscitation was not attempted in 1975 cases because of late arrival, or a severe pre-existing pathological state. Resuscitation was therefore attempted in 2026 patients and a stable haemodynamic state was obtained in 739. Fatal recurrences of cardiac arrest occurred during transport to hospital in 230. Two hundred and nine patients were excluded because of age or because the cardiac
Discussion
The rate of coronary artery spasm as a cause of cardiac arrest is difficult to determine because of conflicting data. Studies with no systematic provocation test performed before discharge of survivors report rates of less than 2% [7], [8]. In contrast, in ten selected survivors with no cardiac or coronary underlying disease, Igarashi et al. diagnosed coronary artery spasm in seven [14]. In our study, immediate coronary angiogram was performed at admission in all patients, and repeated with a
Study limitations
In our study only survivors with no obvious non-cardiac cause of cardiac arrest prior to admission who were between 30 and 75 years of age were included. Our determination of the prevalence of coronary artery spasm is therefore limited to this selected population. Nevertheless, resuscitation is rarely successful in patients >75 years and our results may therefore be extended to unselected survivors with OHCA. In our series, provocation tests were only performed in survivors with no or minimal
Conclusion
In a consecutive series of 300 survivors of OHCA, coronary artery spasm was demonstrated in ten. Our results stress the importance of coronary angiogram and provocation tests in survivors of OHCA since prompt recognition of coronary artery spasm as the cause of arrest allows treatment with calcium channel antagonists. Residual spasm at 1 month in this setting is frequent and the efficacy of medical treatment should therefore be assessed by repetitive provocation tests. In patients with
References (22)
- et al.
Cardiac arrest associated with coronary artery spasm
Am. J. Cardiol.
(1987) - et al.
Arrhythmic cardiac arrest due to isolated coronary artery spasm: long-term outcome of seven resuscitated patients
J. Am. Coll. Cardiol.
(1998) - et al.
Coronary angiographic morphology in myocardial infarction: a link between the pathogenesis of unstable angina and myocardial infarction
J. Am. Coll. Cardiol.
(1985) - et al.
Angiographic coronary morphology in survivors of cardiac arrest
Am. Heart J.
(1988) - et al.
Coronary artery stent placement in patients with variant angina refractory to medical treatment
Am. J. Cardiol.
(1999) - et al.
Risk factors for sudden death in middle-aged British men
Circulation
(1995) - Wyse DG, Friedman PL, Brodsky MA, et al.; the AVID investigators. Life-threatening ventricular arrhythmias due to...
- et al.
Factors associated with survival to hospital discharge among patients hospitalized alive after out of hospital cardiac arrest: change in outcome over 20 years in the community of Goteborg, Sweden
Heart
(2003) Sudden cardiac death. Future approaches
Circulation
(1992)- et al.
Thrombosis and acute coronary-artery lesions in sudden cardiac ischemic death
N. Engl. J. Med.
(1984)
Immediate coronary angiography in survivors of out-of-hospital cardiac arrest
N. Engl. J. Med.
Cited by (39)
Pharmacological coronary spasm provocative testing in clinical practice: A French Coronary Atheroma and Interventional Cardiology Group (GACI) position paper
2023, Archives of Cardiovascular DiseasesRecurrent out-of-hospital cardiac arrest related to triple-vessel coronary artery spasm: A case report
2023, HeartRhythm Case ReportsAbnormal epicardial coronary vasomotor reactivity is associated with altered outcomes
2023, Archives of Cardiovascular DiseasesCitation Excerpt :Indeed, whereas standard diagnostic procedures can confirm or refute significant CAD in patients with chest pain at rest, none addresses the possibility of ACVR. Undiagnosed – and thus untreated – ACVR may expose the patient to severe and life-threatening complications, including ventricular arrhythmias, myocardial infarction (MI) [9,10] or cardiac sudden death [9–11], and to repeated and expensive investigations. The diagnostic strategy in our institution has been to perform a PT in every patient presenting with chest pain at rest, for whom coronary angiography did not reveal significant epicardial CAD (≥ 70% stenosis by visual assessment).
Safety and usefulness of acetylcholine provocation test in patients with no culprit lesions on emergency coronary angiography
2018, International Journal of CardiologySudden cardiac death and coronary thrombus
2017, Annales de Cardiologie et d'Angeiologie