963 □ CASE REPORT □ Refractory Vasospasms of the Coronary Arteries due to Multiple Factors: An Autopsy Case Kentaro Arakawa 1 , Hideo Himeno 1 , Toshikazu Gondo 2 , Jin Kirigaya 1 , Fumie Otomo 1 , Kensuke Matsushita 1 , Hidefumi Nakahashi 1 , Satoru Shimizu 1 , Manabu Nitta 1 , Hideto Yano 1 , Mitsuaki Endo 1 , Kazuo Kimura 3 and Satoshi Umemura 4 Abstract A 41-year-old man was admitted with decompensated heart failure. Mechanical ventilation was maintained with a large dose of propofol. On day 4, significant ST elevation with complete atrioventricular block was noted, which subsequently induced cardiopulmonary arrest. Treatment with percutaneous cardiopulmonary support and therapeutic hypothermia was initiated. Emergent cardiac angiography showed simultaneous mul- tivessel coronary spasms. Although nitroglycerin and nicorandil were ineffective, the intracoronary admin- istration of fasudil, a Rho-kinase inhibitor, successfully resolved the vasospasms. However, during rewarming, the coronary vasospasms recurred, and the patient died of cardiogenic shock. In addition to hypertrophy, the autopsied heart demonstrated the accumulation of inflammatory cells in the pericardium and adventitia of the coronary arteries. Key words: coronary artery spasm, inflammation, hypertrophic cardiomyopathy (Intern Med 53: 963-967, 2014) (DOI: 10.2169/internalmedicine.53.1900) Introduction Variant angina, first described by Prinzmetal and col- leagues in 1959, is caused by severe coronary vasospasms associated with transmural myocardial ischemia (1). Most patients respond to nitrates or calcium channel blockers. However, in some cases, medical treatment-resistant vaso- spasms have been reported. We herein present an autopsy case of vasospastic angina refractory to conventional ther- apy. Multiple factors are associated with the occurrence of coronary vasospasms that cannot be relieved with medical management. Case Report A 41-year-old man was admitted to our hospital with dyspnea and chest pain. Cardiomegaly and pulmonary ve- nous congestion were evident on a chest roentgenogram. Electrocardiography and the laboratory data showed no evi- dence of myocardial ischemia (Fig. 1). An echocardiogram demonstrated concentric hypertrophy and a reduced systolic function of the left ventricle (Fig. 2A, B). Mechanical venti- lation was induced and maintained with a large dose of in- travenous propofol. To treat the acute decompensated heart failure, a continuous infusion of carperitide and nitroglycerin was administered in addition to diuretics. On day 4, signifi- cant ST elevation was noted on the telemetry monitor. Sub- sequent electrocardiography revealed ST elevation in leads II, III and aVF with complete atrioventricular block, which subsequently induced cardiopulmonary arrest (Fig. 3). The patient received prolonged cardiopulmonary resuscitation and percutaneous cardiopulmonary support with therapeutic hypothermia. Emergent cardiac angiography showed diffuse severe narrowing of the right coronary artery (RCA) and to- tal occlusion of the mid left anterior descending artery 1 Division of Cardiology, Fujisawa City Hospital, Japan, 2 Division of Pathology, Fujisawa City Hospital, Japan, 3 Division of Cardiology, Yoko- hama City University Medical Center, Japan and 4 Department of Medical Science and Cardiorenal Medicine, Yokohama City University, School of Medicine, Japan Received for publication October 9, 2013; Accepted for publication November 24, 2013 Correspondence to Dr. Kentaro Arakawa, [email protected]
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963
□ CASE REPORT □
Refractory Vasospasms of the Coronary Arteries due toMultiple Factors: An Autopsy Case
Intern Med 53: 963-967, 2014 DOI: 10.2169/internalmedicine.53.1900
964
Figure 1. A chest X-ray and electrocardiogram obtained on admission. A: A decubitus anteropos-terior chest X-ray showing cardiomegaly and pleural effusion. B: A 12-lead electrocardiogram show-ing sinus tachycardia, biatrial enlargement and left ventricular hypertrophy.
Figure 2. A transthoracic echocardiogram obtained on admission showing concentric hypertrophy with a reduced systolic function of the left ventricle (A: long-axis view; B: M-mode).
Figure 3. An electrocardiogram obtained immediately prior to cardiopulmonary arrest in the intensive care unit. Marked ST-elevation in the inferior leads and complete atrioventricu-lar block were evident.
(LAD). Intravascular ultrasound demonstrated a myocardial
bridge in the LAD and non-calcified mildly atherosclerotic
lesions with negative arterial remodeling in both the LAD
and RCA, which suggested that the angiographic appearance
was due to multivessel coronary vasospasms (Fig. 4A-D).
However, the repeated intracoronary administration of nitro-
glycerin and nicorandil was ineffective in resolving the
spasms. Therefore, we administered fasudil, a Rho-kinase
inhibitor, into the spastic arteries, which successfully re-
solved the spasms with resolution of the inferior ST eleva-
tion and an improvement in the myocardial ischemia
(Fig. 4E, F). We discontinued the propofol and initiated the
continuous intravenous administration of fasudil. However,
on day 6, during rewarming following treatment with thera-
peutic hypothermia, the ST elevation in the inferior leads
and complete atrioventricular block recurred. The intrave-
nous infusion of hydrocortisone and diltiazem was ineffec-
tive in resolving the myocardial ischemia. The patient’s va-
sopressor requirements increased, and he died of cardiogenic
shock six hours later. An autopsy was carried out 24 hours
after his death. At autopsy, the heart weighted 980 g. Con-
centric hypertrophy of the left ventricle was observed with
extensive myocardial necrosis in the inferior wall. A small
abscess was noted in the pericardial sac. Multiple transverse
Intern Med 53: 963-967, 2014 DOI: 10.2169/internalmedicine.53.1900
965
Figure 4. Coronary angiogram and intravascular ultrasound findings. A, B: Initial angiograms showing diffuse severe narrowing of the right coronary artery (RCA) and total occlusion of the mid left anterior descending artery (LAD). C, D: Intravascular ultrasound images obtained following the intracoronary administration of nitroglycerin demonstrating non-calcified mildly atherosclerotic le-sions with negative arterial remodeling in the RCA (black arrows) and a large myocardial bridge with a myocardial band overlying a segment of the LAD (white arrows). E, F: Final angiograms showing fasudil-induced dilatation with residual fixed narrowing.
sections of the coronary arteries exhibited luminal narrowing
due to the presence of atherosclerotic plaques in 25% to
75% of the cross-sections, including the area involved in the
spasms; however, no occlusion was observed. A histological
examination demonstrated marked hypertrophied and bizarre
myocytes with disarray in addition to the accumulation of
inflammatory cells in the pericardium and adventitia of the
coronary arteries at the site of the vasospasms, even inside
the perivascular nerve tissue (Fig. 5A-F). The infiltrating
cells in the epineurium and endoneurium were primarily
lymphocytes.
Discussion
Simultaneous multivessel coronary spasms, one of the
most severe forms of coronary spastic angina due to the
presence of severe and extensive myocardial ischemia, are
often associated with refractory angina and multiple medica-
tions are often used to relieve the vasospasms (2).
In the present case, even fasudil was only transiently ef-
fective. Several factors are associated with the occurrence of
coronary vasospasms refractory to conventional medications.
First, in patients with hypertrophic cardiomyopathy, an
impaired sympathetic nerve function and the genetic variants
of the delta-sarcoglycan and the endothelial nitric oxide syn-
thase are associated with increased vasomotor activity (3-5).
Additionally, mechanical stimulation at the myocardial
bridge site of the mid LAD induces endothelial dysfunction
and enhanced local susceptibility to vasoconstrictor stim-
uli (6).
Second, the continuous infusion of large doses of propo-
fol can result in autonomic imbalances and lipid metabolic
disorders, including the presence of remnant-like particles
associated with an upregulated Rho-kinase expression in
coronary vascular smooth muscle cells and a markedly en-
hanced coronary vasospastic activity (7).
Intern Med 53: 963-967, 2014 DOI: 10.2169/internalmedicine.53.1900
966
Figure 5. Photomicrographs of the autopsied heart. A: Subserial ventricular myocardial sections of the autopsied heart showing marked diffuse thickening of the left ventricular walls. There is suben-docardial hyperemia (arrowheads) within a nearly transmural inferior myocardial infarct. B: Histo-logical appearance of the left ventricle (non-infarct area). Marked hypertrophied and bizarre myo-cytes with disarray were observed. C: Histological appearance of the pericardium showing the accumulation of inflammatory cells, primarily lymphocytes and macrophages. D: A transverse sec-tion of the right coronary artery at the site of the spasms. Although no coronary thrombi were found, luminal narrowing due to atherosclerotic plaque was evident and the coronary arterial adventitia was thickened with collagen. E, F: Higher magnification views of the areas #1 and #2 in D. Many inflam-matory cells, primarily lymphocytes, were clustered in the adventitia around and even inside the perivascular nerve tissue.
Third, rewarming following treatment with therapeutic hy-
pothermia can trigger the recurrence of vasospasms. Experi-
mental studies of isolated human middle cerebral arteries
have shown that human arteries dilate only slightly with
cooling and undergo a more profound constrictor response
upon rewarming (8). Both an increase in metabolic demands
and ventilator requirements and the massive reproduction of
cytokines and oxygen free radicals can occur during re-
warming (9).
Fourth, inflammation associated with intense pericarditis
may spread to the adventitia of atherosclerotic coronary ar-
teries. Recently, enhanced inflammation in perivascular fat
has been reported to influence vascular homeostasis and the
development of atherosclerosis in coronary arteries (10, 11).
The coronary adventitia is richly innervated with automatic
fibers that form a network around the entire length of each
coronary vessel. The degeneration of these autonomic ner-
vous fibers due to irritation by inflammatory cells induces
irregularities in the sympathetic activity, including the vaso-
motor activity (12). Moreover, chronic inflammation of the
adventitia is reported to induce alterations in smooth muscle
phenotypes toward dedifferentiation (13). In this way, the
smooth muscle cells of the coronary arterial media are
stimulated directly by chemical mediators secreted by in-
flammatory cells or indirectly by irritated autonomic ner-
vous fibers involved in the inflammatory process.
In conclusion, we herein described an autopsy case of re-
fractory vasospasms of the coronary arteries due to multiple
Intern Med 53: 963-967, 2014 DOI: 10.2169/internalmedicine.53.1900
967
factors. Early intervention to address causative factors, such
as providing treatment with calcium channel-blockers and
anti-inflammatory drugs, may help to improve outcomes in
patients with refractory vasospastic angina.
The authors state that they have no Conflict of Interest (COI).
References
1. Prinzmetal M, Kennarmer R, Merliss R, Wada T, Bor N. Angina
pectoris. I. A variant form of angina pectoris; preliminary report.
Am J Med 27: 375-388, 1959.
2. Ogawa H, Suefuji H, Takazoe K, et al. Difference in fibrinolytic
activity between multivessel coronary spasm and one-vessel coro-
nary spasm. Am J Cardiol 85: 98-101, 2000.
3. Matsuo S, Matsumoto T, Nakae I, Horie M. The role of impaired
sympathetic nerve function in enhancing coronary vasoconstriction
in patients with hypertrophic cardiomyopathy. Exp Clin Cardiol