Archives of Cardiovascular Disease (2014) 107, 205—206
Available online at
ScienceDirect www.sciencedirect.com
LETTER TO THE EDITORS Risk of recurrence after lifethreatening ventricular arrhythmias in coronary spasm Risque de récidive des arythmies ventriculaires dans l’angor spastique Keywords: Coronary vasospasm; Implantable defibrillators; Ventricular arrhythmias; Sudden cardiac death Mots clés : Spasme coronaire ; Défibrillateur automatique implantable ; Trouble du rythme ventriculaire ; Mort subite We recently discussed the role of implantable cardioverter defibrillators (ICDs) as a complement to optimal medical management in patients with life-threatening ventricular arrhythmias (VAs) due to coronary artery spasm, in light of three cases managed in our department [1]. As we stated, an ICD is not indicated in primary prevention in patients without a spasm-related life-threatening VA. However, the role of an ICD in secondary prevention after resuscitated sudden cardiac death due to vasospastic angina is unknown. Indeed, several cases reports [2,3] have highlighted the risk of recurrent life-threatening VAs in such patients, despite optimal management (smoking cessation, non-dihydropyridine calcium channel blockers and/or nitrate derivatives [4]). Unfortunately, no clinical trial has been performed to provide definitive conclusions. We have proposed a cascade management strategy based on the results of an ergonovine test after the introduction of optimal medical treatment in such patients, to consider the implantation of an ICD [1]. However, this proposition was based on clinical experience not on evidence-based medicine, which is currently the gold standard in modern cardiology. In our previous review [1], we discussed the case of a 52-year-old woman who was initially managed for a
Abbreviations: ICD, implantable cardioverter defibrillator; VA, ventricular arrhythmia. http://dx.doi.org/10.1016/j.acvd.2014.02.003 1875-2136/© 2014 Published by Elsevier Masson SAS.
first non-ST-segment elevation myocardial infarction with angiographically healthy coronaries and who presented 6 months later with a cardiac arrest treated by two shocks delivered by a semi-automatic defibrillator for ventricular fibrillation due to a recurrent coronary spasm, despite smoking cessation and optimal medical treatment (isosorbide mononitrate, calcium channel blockers, statin and aspirin). We decided to optimize her medical treatment (amlodipine, nicorandil, nifedipine, statin and dual antiplatelet therapy) and to implant an ICD. During the initial follow-up, the ICD interrogation showed several episodes of non-sustained ventricular tachycardia (maximum duration, 14 seconds). During a recent face-to-face consultation, 36 months after ICD implantation, the patient described two episodes of dizziness without any context of stress or risk factors for coronary spasm (no cold environment, smoky atmosphere, etc.). Her medical treatment was unchanged, with perfect observance. The ICD interrogation showed two episodes of rapid ventricular tachycardia and ventricular fibrillation, well detected and successfully treated by antitachycardia pacing and one intracardiac shock (39.2 J) (Fig. 1). This observation confirmed that the role of an ICD after lifethreatening VA is important to define. It appears crucial to create a national registry of patients with an ICD implanted after a resuscitated sudden cardiac death due to life-threatening VAs during a coronary artery spasm. This registry may be helpful in evaluating the prevalence and incidence of such patients, but also to evaluate the recurrence of life-threatening VAs, despite the introduction of optimal medical management and the removal of risk factors. Indeed, the key point is to evaluate whether the risk of sudden cardiac death is completely removed by optimal management or whether such patients display a specific trigger or spasm susceptibility that is undercontrolled by optimal medical treatment, leading to ICD implantation. According to these results, a multicentre randomized clinical trial should be performed.
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Letter to the Editors
Figure 1. Ventricular fibrillation detected by an implantable cardioverter defibrillator (Paradym VR; Sorin Group) and successfully treated by an intracardiac shock (39.2 J).
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Eschalier R, Souteyrand G, Jean F, et al. Should an implanted defibrillator be considered in patients with vasospastic angina? Arch Cardiovasc Dis 2014;107:42—7. [2] Al-Sayegh A, Shukkur AM, Akbar M. Automatic implantable cardioverter defibrillator for the treatment of ventricular fibrillation following coronary artery spasm: a case report. Angiology 2007;58:122—5. [3] Hendriks ML, Allaart CP, Bronzwaer JG, et al. Recurrent ventricular fibrillation caused by coronary artery spasm leading to implantable cardioverter defibrillator implantation. Europace 2008;10:1456—7. [4] Yasue H, Takizawa A, Nagao M, et al. Long-term prognosis for patients with variant angina and influential factors. Circulation 1988;78:1—9.
Romain Eschalier a,b,∗ , Pascal Motreff a,b , Pierre Bordachar c a
Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France b Cardio-Vascular Interventional Therapy and Imaging (CaVITI), Image Science for Interventional Techniques (ISIT), UMR6284, Clermont Université, Université d’Auvergne, Clermont-Ferrand, France c Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Université Bordeaux, IHU LIRYC, Bordeaux, France ∗ Corresponding
author. Cardiology Department, Clermont-Ferrand University Hospital, 58, rue Montalembert, 63000 Clermont-Ferrand, France. E-mail address: [email protected] (R. Eschalier) Received 9 February 2014; accepted 12 February 2014 Available online 4 April 2014
Available online at
ScienceDirect www.sciencedirect.com
LETTER TO THE EDITORS Risk of recurrence after lifethreatening ventricular arrhythmias in coronary spasm Risque de récidive des arythmies ventriculaires dans l’angor spastique Keywords: Coronary vasospasm; Implantable defibrillators; Ventricular arrhythmias; Sudden cardiac death Mots clés : Spasme coronaire ; Défibrillateur automatique implantable ; Trouble du rythme ventriculaire ; Mort subite We recently discussed the role of implantable cardioverter defibrillators (ICDs) as a complement to optimal medical management in patients with life-threatening ventricular arrhythmias (VAs) due to coronary artery spasm, in light of three cases managed in our department [1]. As we stated, an ICD is not indicated in primary prevention in patients without a spasm-related life-threatening VA. However, the role of an ICD in secondary prevention after resuscitated sudden cardiac death due to vasospastic angina is unknown. Indeed, several cases reports [2,3] have highlighted the risk of recurrent life-threatening VAs in such patients, despite optimal management (smoking cessation, non-dihydropyridine calcium channel blockers and/or nitrate derivatives [4]). Unfortunately, no clinical trial has been performed to provide definitive conclusions. We have proposed a cascade management strategy based on the results of an ergonovine test after the introduction of optimal medical treatment in such patients, to consider the implantation of an ICD [1]. However, this proposition was based on clinical experience not on evidence-based medicine, which is currently the gold standard in modern cardiology. In our previous review [1], we discussed the case of a 52-year-old woman who was initially managed for a
Abbreviations: ICD, implantable cardioverter defibrillator; VA, ventricular arrhythmia. http://dx.doi.org/10.1016/j.acvd.2014.02.003 1875-2136/© 2014 Published by Elsevier Masson SAS.
first non-ST-segment elevation myocardial infarction with angiographically healthy coronaries and who presented 6 months later with a cardiac arrest treated by two shocks delivered by a semi-automatic defibrillator for ventricular fibrillation due to a recurrent coronary spasm, despite smoking cessation and optimal medical treatment (isosorbide mononitrate, calcium channel blockers, statin and aspirin). We decided to optimize her medical treatment (amlodipine, nicorandil, nifedipine, statin and dual antiplatelet therapy) and to implant an ICD. During the initial follow-up, the ICD interrogation showed several episodes of non-sustained ventricular tachycardia (maximum duration, 14 seconds). During a recent face-to-face consultation, 36 months after ICD implantation, the patient described two episodes of dizziness without any context of stress or risk factors for coronary spasm (no cold environment, smoky atmosphere, etc.). Her medical treatment was unchanged, with perfect observance. The ICD interrogation showed two episodes of rapid ventricular tachycardia and ventricular fibrillation, well detected and successfully treated by antitachycardia pacing and one intracardiac shock (39.2 J) (Fig. 1). This observation confirmed that the role of an ICD after lifethreatening VA is important to define. It appears crucial to create a national registry of patients with an ICD implanted after a resuscitated sudden cardiac death due to life-threatening VAs during a coronary artery spasm. This registry may be helpful in evaluating the prevalence and incidence of such patients, but also to evaluate the recurrence of life-threatening VAs, despite the introduction of optimal medical management and the removal of risk factors. Indeed, the key point is to evaluate whether the risk of sudden cardiac death is completely removed by optimal management or whether such patients display a specific trigger or spasm susceptibility that is undercontrolled by optimal medical treatment, leading to ICD implantation. According to these results, a multicentre randomized clinical trial should be performed.
206
Letter to the Editors
Figure 1. Ventricular fibrillation detected by an implantable cardioverter defibrillator (Paradym VR; Sorin Group) and successfully treated by an intracardiac shock (39.2 J).
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Eschalier R, Souteyrand G, Jean F, et al. Should an implanted defibrillator be considered in patients with vasospastic angina? Arch Cardiovasc Dis 2014;107:42—7. [2] Al-Sayegh A, Shukkur AM, Akbar M. Automatic implantable cardioverter defibrillator for the treatment of ventricular fibrillation following coronary artery spasm: a case report. Angiology 2007;58:122—5. [3] Hendriks ML, Allaart CP, Bronzwaer JG, et al. Recurrent ventricular fibrillation caused by coronary artery spasm leading to implantable cardioverter defibrillator implantation. Europace 2008;10:1456—7. [4] Yasue H, Takizawa A, Nagao M, et al. Long-term prognosis for patients with variant angina and influential factors. Circulation 1988;78:1—9.
Romain Eschalier a,b,∗ , Pascal Motreff a,b , Pierre Bordachar c a
Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France b Cardio-Vascular Interventional Therapy and Imaging (CaVITI), Image Science for Interventional Techniques (ISIT), UMR6284, Clermont Université, Université d’Auvergne, Clermont-Ferrand, France c Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Université Bordeaux, IHU LIRYC, Bordeaux, France ∗ Corresponding
author. Cardiology Department, Clermont-Ferrand University Hospital, 58, rue Montalembert, 63000 Clermont-Ferrand, France. E-mail address: [email protected] (R. Eschalier) Received 9 February 2014; accepted 12 February 2014 Available online 4 April 2014
