Cath Lab Digest - September 2007 - (Page 24)

24 CASE REPORT AND REVIEW SEPTEMBER 2007 Myocardial Infarction and Syncope: A manifestation of the “Raynaud-Prinzmetal Syndrome”? Jack P. Chen, MD, FACC, FSCAI, FCCP Chairman, Department of Cardiology, Northside Hospital Atlanta, Georgia Figure 1. Ambulance rhythm strip revealing profound sinus bradycardia and ST segment elevation in lead II. Abstract. Patients with Raynaud’s disease or phenomenon manifest arterial vasospasm in various circulatory beds. These episodes can be triggered by stresses such as cold exposure. However, definitive involvement of the coronary vasculature, although suggested, has never been demonstrated. Such coronary vasospasm, also known as Prinzmetal’s or variant angina, is rarely associated with frank myocardial infarction. We hereby present a patient with a history of Raynaud’s phenomenon, who suffered an STsegment elevation myocardial infarction, complicated by bradycardia and syncope. Emergent cardiac catheterization revealed no coronary stenoses, a finding suggestive of transient coronary spasm. She had an uncomplicated course, and long-acting nitrates were added to her previous Raynaud’s medical regimen of nifedipine. The similarities in pathophysiologies and treatments of both Raynaud’s and Prinzmetal’s phenomena are discussed. Our case is a rare exception to the usual benign prognosis associated with Prinzmetal’s angina. We further propose that our patient may represent an overlap global vasospastic syndrome, encompassing the coronary as well as the peripheral circulation. Figure 2. Initial 12-lead electrocardiogram demonstrating continued sinus bradycardia with inferolateral Q waves and ST segment elevations. Reciprocal ST segment depressions are seen in the remaining leads. Case Report A 54-year-old woman without previous cardiovascular history was transported via ambulance to an outside instituton after a syncopal episode. While delivering a presentation at work, she experienced a 30second prodrome of dizziness prior to collapsing to the floor. Upon recovery of consciousness, the patient denied chest pain, dyspnea, further dizziness or other symptoms. Rhythm strip (lead II) from the emergency medical service revealed marked sinus bradycardia at 37 beats per minute, with prominent ST-segment elevations, consistent with acute myocardial infarction (Figure 1). Her past medical history was significant for Raynaud’s disease, characterized mainly by cold-induced fingertip pallor and pain. Otherwise, she had mild hypertension and hyperlipidemia, was a former smoker and exercised regularly. Medications included extended-release nifedipine and simvastatin. Her family history was significant for premature coronary disease. She did admit to a “high-strung” personality and reported that it had been an important presentation. While in the emergency department, 12-lead electrocardiogram again demonstrated sinus bradycardia, with Q waves and 3- to 4-mm ST segment elevations in the inferolateral leads as well as accompanying depressions in the reciprocal leads (Figure 2). Shortly thereafter, the vital signs had normalized, with heart rate of 62 beats per minute and blood pressure of 121/67 mmHg. Repeat electrocardiogram now revealed near-resolution of the ST-segment elevations, with new inferior T-wave inversions (Figure 3). Initial cardiac markers revealed creatinine kinase of 110 IU/L, creatinine kinase-MB fraction of 2.70 ng/mL, and elevated troponin I of 0.13 ng/mL. The patient was subsequently transferred to our hospital, and emergency cardiac catheterization revealed no significant stenoses in either the left (Figure 4) or right (Figure 5) coronary arteries. Left ventricular function and size were within normal limits, without evidence of regional wall motion abnormalities (Figure 6). She remained Figure 3. Subsequent 12-lead electrocardiogram showing nearresolution of the ST segment deflections and new T wave inversions inferiorly. asymptomatic, with stable hemodynamics, and was discharged the following day. Electrocardiographically, the inferior Q-waves and T-wave inversions persisted and cardiac markers revealed a moderate-sized infarct. Long-acting nitrate, sublingual immediate-acting nitroglycerine (to take as needed), and aspirin were added to her previous medical regimen of nifedipine and simvastatin. or variant angina. Although spontaneous thrombolysis and resolution of acute plaque rupture was another possible etiology, the extreme rapidity of onset and offset of symptoms and electrocardiographic findings would be atypical for that presentation. First described in 1959, the syndrome of CV usually presents as anginal episodes accompanied by transient ST-segment elevations, often associated with times of emotional stress.1 Compromised right coronary artery (RCA) flow from such CV can manifest as profound bradycardia, from either sino-atrial or atrio-ventricular node ischemia. In our case, the slow Discussion The above case may have represented an unusual and impressive presentation of right coronary vasospasm (CV), otherwise known as Prinzmetal’s The author has no financial or proprietary interest/conflict. This article is a case report and therefore not submitted to the institutional review board.

Table of Contents Feed for the Digital Edition of Cath Lab Digest - September 2007

St. Dominic Hospital The Genous Bio-engineered R Stent Percutaneous Treatment of Peripheral Arterial Chronic Total Occlusions: Device Options and Clinical Outcomes Contents Clinical Editor’s Corner Percutaneous Revascularization of Peripheral Chronic Total Occlusion — Which Patients, Why, and How? Myocardial Infarction and Syncope: A Manifestation of the “Raynaud-Prinzmetal Syndrome”? Essential Technical Components of the Transradial Approach If You Build It, Will They Come? Evidence-Based Medicine with Drug-Eluting Stents Back to School: The Value of Education in Cardiovascular Services The ACVP Standards and Competencies: Are You Using Them Effectively? What Do You Think? My Experience with Fibromuscular Dysplasia and Stroke A Brief Review of Fibromuscular Dysplasia Letter to the Editor A Look at On-the-Job Training: Perceptions, Reality and Our Profession Doing the Wave: Inventory Management with RFID The Ten-Minute Interview with… Paul Pinsker, RCIS CLD’s Annual Salary Survey Harrisburg Area Community College Volunteer Survey CEU Education Center SICP* Section Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Clinical & Industry News

Cath Lab Digest - September 2007

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