Tekrarlayan Kardiyak Arrest ve Ventriküler Fibrilasyon ile Prezente Olan Rekürren Vazospastik Anjina

Öz

Giriş: Vazospastik anjina (VSA), geçici koroner vazospazm ile karakterize, potansiyel olarak ölümcül bir miyokardiyal iskemi nedenidir. Genellikle yönetilebilir olmakla birlikte, hayatı tehdit eden ventriküler aritmiler ve kardiyak arreste yol açabilir. Olgu Sunumu: 45 yaşında kadın hasta, 15 aylık sürede üç kardiyak arrest epizodu yaşadı. Her olayda EKG'de ST yükselmesi ve anjiyografik olarak doğrulanan, intrakoroner nitrogliserin ile düzelen kritik çok damarlı vazospazm (LMCA, LAD, LCx) mevcuttu. Başlangıçta uygulanan diltiazem ve nitrat tedavisi, ilaç uyumsuzluğunun da katkısıyla nüksleri önleyemedi. İkinci arrest sonrası implante edilen implante edilebilir kardiyoverter-defibrilatör (ICD) şok vererek devreye girdi. Üçüncü arrestin ardından düşük sol ventrikül ejeksiyon fraksiyonu (LVEF: %35-40) nedeniyle diltiazem nebivolole (5 mg/gün) değiştirildi; izosorbid mononitrat (40 mg/gün) ise nitratsız aralık uygulanarak sürdürüldü. Beş aylık takipte hasta bu rejimle semptomsuz kalmıştır. Sonuç: Bu olgu, refrakter ventriküler aritmiler ve tekrarlayan arrest dahil VSA'nın yaşamı tehdit eden potansiyelini ortaya koymaktadır. Yüksek riskli hastalarda sürekli tedaviye uyum ve ICD'nin kritik rolünü vurgulamaktadır.

Anahtar Kelimeler

• Vazospastik anjin
• Prinzmetal anjini
• Koroner vazospazm
• Kardiyak arrest
• İntrakoroner nitrat
• İlaç uyumu

Recurrent Vasospastic Angina Presenting as Recurrent Cardiac Arrest and Ventricular Fibrillation

Öz

Introduction: Vasospastic angina (VSA) is a potentially lethal cause of myocardial ischemia characterized by transient coronary vasospasm. While typically manageable, it can provoke life-threatening ventricular arrhythmias and cardiac arrest. Case Presentation: A 45-year-old woman experienced three cardiac arrests over 15 months. Each event featured ST-elevation on ECG and critical multi-vessel spasm (LMCA, LAD, LCx) confirmed angiographically, resolving with intracoronary nitroglycerin. Initial treatment with diltiazem and nitrates failed to prevent recurrences, complicated by medication non-adherence. An ICD implanted after the second arrest delivered shocks. After the third arrest, reduced LVEF (35-40%) necessitated switching from diltiazem to nebivolol (5 mg/day), while isosorbide mononitrate (40 mg/day) was continued with a nitrate-free interval. At 5-month follow-up, the patient remained symptom-free on this regimen. Conclusion: This case illustrates VSA’s life-threatening potential, including refractory ventricular arrhythmias and recurrent arrest. It underscores the critical role of sustained pharmacotherapy adherence and ICDs in high-risk patients.

Anahtar Kelimeler

• Vasospastic angina
• Prinzmetal angina
• Coronary vasospasm
• Cardiac arrest
• Intracoronary nitrate
• Medication adherence

Kaynakça

1. 1. Jenkins K, Pompei G, Ganzorig N, Brown S, Beltrame J, Kunadian V. Vasospastic angina: a review on diagnostic approach and management. Ther Adv Cardiovasc Dis. 2024;18:17539447241230400. doi:10.1177/17539447241230400
2. 2. Beltrame JF, Crea F, Kaski JC, Ogawa H, Ong P, Sechtem U, et al. International standardization of diagnostic criteria for vasospastic angina. Eur Heart J. 2017;38(33):2565-2568. doi:10.1093/eurheartj/ehv351
3. 3. Hokimoto S, Kaikita K, Yasuda S, Tsujita K, Ishihara M, Matoba T, et al. (Japanese Circulation Society and Japanese Association of Cardiovascular Intervention and Therapeutics and Japanese College of Cardiology Joint Working Group). JCS/CVIT/JCC 2023 Guideline Focused Update on Diagnosis and Treatment of Vasospastic Angina (Coronary Spastic Angina) and Coronary Microvascular Dysfunction. Circ J. 2023;87(6):879-936. doi:10.1253/circj.CJ-22-0779
4. 4. Cai H, Chen S, Wang D. Sudden diffuse spasm of multiple coronary arteries: a case report. Medicine (Baltimore). 2024;103(2):e36889. doi:10.1097/MD.0000000000036889
5. 5. Güzel T. A rare case of vasospasm presenting with acute coronary syndrome and leading to total occlusion. Turk Kardiyol Dern Ars. 2023;51(6):415-418. doi:10.5543/tkda.2023.73858
6. 6. Montone RA, Niccoli G, Fracassi F, Russo M, Gurgoglione F, Cammà G, et al. Patients with acute myocardial infarction and non-obstructive coronary arteries: safety and prognostic relevance of invasive coronary provocative tests. Eur Heart J. 2018;39(2):91-98. doi:10.1093/eurheartj/ehx667
7. 7. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009;119(14):e391-e479. doi:10.1161/CIRCULATIONAHA.109.192065
8. 8. Kook H, Hong SJ, Yang KS, Lee S, Kim JS, Park CG. Comparison of nebivolol versus diltiazem in improving coronary artery spasm and quality of life in patients with hypertension and vasospastic angina: a prospective, randomized, double-blind pilot study. PLoS One. 2020;15(9):e0239039. doi:10.1371/ journal.pone.0239039

9. 9. Takagi Y, Yasuda S, Tsunoda R, Ogata Y, Seki A, Sumiyoshi T, et al. Clinical characteristics and long-term prognosis of vasospastic angina patients who survived out-of-hospital cardiac arrest: multicenter registry study of the Japanese Coronary Spasm Association. Circ Arrhythm Electrophysiol. 2011;4(3):295-302. doi:10.1161/CIRCEP.110.959809
10. 10. Balasubramanian S, Chowdhury YS. Isosorbide. [Updated 2023 May 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https:// www.ncbi.nlm.nih.gov/books/NBK557839/
11. 11. Bhandari B, Kanderi T, Yarlagadda K, Qureshi M, Komanduri S. Coronary vasospasm as an etiology of recurrent ventricular fibrillation in the absence of coronary artery disease: a case report. J Community Hosp Intern Med Perspect. 2021;11(4):510-515. doi:10.1080/20009666.2021.1915534