Clinical Implications of an Implantable Cardioverter-Defibrillator in Patients With Vasospastic Angina and Lethal Ventricular Arrhythmia

Jul 25, 2012
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Authors:
Matsue Y, Suzuki M, Nishizaki M, et al.
Citation:
J Am Coll Cardiol 2012;Jul 25:[Epub ahead of print].
Summary By:
Fred Morady, MD, FACC

Study Questions:

Is an implantable cardioverter-defibrillator (ICD) appropriate for patients with vasospastic angina (VSA) who survive a cardiac arrest?

Methods:

This was a retrospective review of 23 patients (mean age 58 years) successfully resuscitated from a cardiac arrest who were found to have coronary artery spasm during an acetylcholine provocation test and received an ICD. None of the patients had an abnormal electrocardiogram, structural heart disease, or a family history of sudden death. Study endpoints were appropriate ICD therapies and cardiac arrest due to pulseless electrical activity (PEA) or asystole.

Results:

All patients were treated with diltiazem and 60% were treated with nitrates. During a mean follow-up of 2.9 years, there were no deaths, but four patients experienced an appropriate ICD therapy for ventricular fibrillation (VF), and one patient had a cardiac arrest due to PEA. None of the four patients with VF had chest pain before the ICD shock. There were no significant differences in patient characteristics or medications between patients with and without VF/PEA during follow-up.

Conclusions:

Patients with VSA who have survived a cardiac arrest remain at high risk of VF despite medical therapy, and are appropriate candidates for an ICD.

Perspective:

Although all of the patients in this study had coronary spasm in response to acetylcholine challenge, it is noteworthy that none of the patients with VF during follow-up had a prodrome of chest pain, and that the VF occurred despite treatment with diltiazem. It is possible that some of the patients had idiopathic VF and incidental coronary spasm in response to acetylcholine, reinforcing the need for an ICD in these types of patients.

Keywords: Defibrillators, Follow-Up Studies, Ventricular Fibrillation, Heart Arrest, Electrocardiography, Heart Diseases, Coronary Vasospasm, Chest Pain, Cardiology, Coronary Vessels


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