Elsevier

Resuscitation

Volume 58, Issue 2, August 2003, Pages 145-152
Resuscitation

Diagnosis and management of out-of-hospital cardiac arrest secondary to coronary artery spasm

https://doi.org/10.1016/S0300-9572(03)00149-7Get rights and content

Abstract

Objective: The clinical features of coronary artery spasm as a cause of cardiac arrest were determined in a prospective study on out-of-hospital cardiac arrest (OHCA). Methods: Coronary angiography was performed at admission in 300 consecutive patients with no obvious non-cardiac cause of OHCA. In survivors with no or minimal coronary artery stenosis, a second angiography with provocation test and electrophysiological testing were performed at 1 month. Results: Spasm was demonstrated in ten patients. Diagnosis was based upon (1) spontaneous spasm on the admission angiogram (3 patients), (2) transient significative ST-segment elevation at follow-up in patients with no or non-significant coronary artery lesions (4 patients) and (3) spasm during the 1 month provocation test (3 patients). Six patients survived at 1 month; spasm occurred during a new provocation test in five despite treatment with high dosage calcium channel blockers leading to coronary stenting in two, an internal cardiovertor defibrillator in one, and increased drug therapy with prolonged hospitalization in the remainder. At a mean follow-up of 55±27 months, no recurrent cardiac arrest occurred. Conclusion: Systematic coronary angiograms and provocation tests in survivors of OHCA allow prompt diagnosis of coronary artery spasm. Residual spasm despite treatment with calcium channel blockers is frequent. Therapy should therefore be guided by repetitive provocation tests, and seems to avoid recurrence of cardiac arrest.

Sumàrio

Objectivo: As caracterı́sticas clı́nicas do espasmo coronário enquanto causa de paragem cardı́aca foram determinados num estudo prospectivo de paragem cardı́aca extra-hospitalar (OHCA). Foi feita coronariografia em 300 doentes consecutivos, sem evidência óbvia de causa de paragem não cardı́aca. Nos sobreviventes sem estenose ou com estenose coronária mı́nima foi feita um mês depois nova coronariografia com testes de provocação e testes electrofisiológicos. Resultados: Em dez desses doentes foi demonstrado espasmo. O diagnóstico foi sustentado por espasmo espontâneo na angiografia de admissão (3 doentes), elevação significativa e transitória do segmento ST no follow-up de doente sem ou com estenose coronária significativa (4 doentes), espasmo durante os testes de provocação ao fim do primeiro mês (3 doentes). Seis desses doentes sobreviveram até ao primeiro mês e voltou a ocorrer espasmo com o teste provocativo em cinco deles, apesar das elevadas doses de bloqueadores dos canais de Ca, o que levou à colocação de stent em dois deles, a implantação de um desfibrilhador-cardioversor noutro e o aumento dos medicamentos e prolongamento da hospitalização nos restantes. Aos 55±27 meses de um follow-up médio, não ocorreram novas paragens cardı́acas recorrentes. Conclusões: coronariografias sistemáticas e testes de provocação nos sobreviventes de OHCA permitem diagnosticar de imediato os espasmos coronários. É frequente a existência de espasmos residuais apesar do tratamento com bloqueadores dos canais de cálcio. O tratamento deve então ser orientado por testes provocativos e parece prevenir novas paragens cardı́acas.

Resumen

Objetivo: Los aspectos clı́nicos del espasmo de arteria coronaria como causa de paro cardı́aco se determinaron en un estudio prospectivo acerca de paro cardı́aco extrahospitalario (OHCA). Métodos: Se realizó una angiografı́a coronaria en 300 pacientes consecutivos admitidos con OHCA sin causa no cardı́aca obvia. En los sobrevivientes sin estenosis coronaria o con estenosis mı́nima se realizó después de un mes una segunda angiografı́afı́a con test de provocación y pruebas electofisiológicas. Resultados: Se demostró espasmo coronario en 10 pacientes. El diagnóstico se basó en (1) espasmo espontáneo en el angiograma hecho en admisión (3 pacientes), (2) elevación transitoria significativa del segmento ST en el seguimiento de pacientes con lesión no significativa o sin lesión de arteria coronaria (4 pacientes) y (3) espasmo durante la prueba de provocación realizada un mes después de la admisión (3 pacientes). 6 pacientes sobrevivieron un mes; el espasmo ocurrió durante una nueva prueba de provocación en 5, pese al tratamiento con altas dosis de bloqueadores de canales de calcio que llevaron a uso de stent en 2, implante de un cardiovertor desfibrilador interno en uno, y una terapia con drogas aumentadas con hospitalización prolongada en el resto. Un seguimiento promedio de 55±27 meses, no hubo ocurrencia de paro cardı́aco recurrente. Conclusión: Las angiografı́as coronarias y las pruebas de provocación sistemáticas permiten el diagnóstico oportuno de espasmo coronario en sobrevivientes. El espasmo residual pese al tratamiento con bloqueadores de canales de calcio es frecuente. Por lo tanto la terapia deberı́a ser guiada por pruebas de provocación repetitiva, y pareciera evitar la recurrencia de paro cardı́aco.

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

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