The Korean journal of internal medicine

The Korean Association of Internal Medicine (대한내과학회)
권호 표지
DOI QR코드

DOI QR Code

Masked inherited primary arrhythmia syndromes in sudden cardiac death patients accompanied by coronary vasospasm

  • Lee, Ki Hong (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Park, Hyung Wook (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Eun, Jeong Nam (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Cho, Jeong Gwan (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Yoon, Nam Sik (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Kim, Mi Ran (Department of Nursing, Chunnam Techno University) ;
  • Ku, Yo Han (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Park, Hyukjin (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Lee, Seung Hun (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Kim, Jeong Han (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Kim, Min Chul (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Kim, Woo Jin (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Kim, Hyun Kuk (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Cho, Jae Yeong (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Park, Keun-Ho (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Sim, Doo Sun (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Yoon, Hyun Ju (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Kim, Kye Hun (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Hong, Young Joon (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Kim, Ju Han (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Ahn, Youngkeun (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Jeong, Myung Ho (Department of Cardiovascular Medicine, Chonnam National University Hospital) ;
  • Park, Jong Chun (Department of Cardiovascular Medicine, Chonnam National University Hospital)
  • Received : 2015.08.20
  • Accepted : 2015.12.06
  • Published : 2017.09.01
⟨ Previous Next ⟩

Abstract

Background/Aims: Coronary vasospasms are one of the important causes of sudden cardiac death (SCD). Provocation of coronary vasospasms can be useful, though some results may lead to false positives, with patients potentially experiencing recurrent SCD despite appropriate medical treatments. We hypothesized that it is not coronary vasospasms but inherited primary arrhythmia syndromes (IPAS) that underlie the development of SCD. Methods: We analyzed 74 consecutive patients (3.8%) who survived out-of-hospital cardiac arrest among 1,986 patients who had angiographically proven coronary vasospasms. Electrical abnormalities were evaluated in serial follow-up electrocardiograms (ECGs) during and after the index event for a 3.9 years median follow-up. Major clinical events were defined as the composite of death and recurrent SCD events. Results: Forty five patients (60.8%) displayed electrocardiographic abnormalities suggesting IPAS: Brugada type patterns in six (8.2%), arrhythmogenic right ventricular dysplasia patterns in three (4.1%), long QT syndrome pattern in one (2.2%), and early repolarization in 38 (51.4%). Patients having major clinical events showed more frequent Brugada type patterns, early repolarization, and more diffuse multivessel coronary vasospasms. Brugada type pattern ECGs (adjusted hazard ratio [HR], 4.22; 95% confidence interval [CI], 1.16 to 15.99; p = 0.034), and early repolarization (HR, 2.97; 95% CI, 1.09 to 8.10; p = 0.034) were ultimately associated with an increased risk of mortality. Conclusions: Even though a number of aborted SCD survivors have coronary vasospasms, some also have IPAS, which has the potential to cause SCD. Therefore, meticulous evaluations and follow-ups for IPAS are required in those patients.

Keywords

Acknowledgement

Supported by : The Korea Centers for Disease Control and Prevention, Ministry of Health and Welfare

References

  1. Tester DJ, Ackerman MJ. The role of molecular autopsy in unexplained sudden cardiac death. Curr Opin Cardiol 2006;21:166-172. https://doi.org/10.1097/01.hco.0000221576.33501.83
  2. Myerburg RJ, Kessler KM, Mallon SM, et al. Life-threatening ventricular arrhythmias in patients with silent myocardial ischemia due to coronary-artery spasm. N Engl J Med 1992;326:1451-1455. https://doi.org/10.1056/NEJM199205283262202
  3. Moss AJ, Schwartz PJ, Crampton RS, Locati E, Carleen E. The long QT syndrome: a prospective international study. Circulation 1985;71:17-21. https://doi.org/10.1161/01.CIR.71.1.17
  4. Gaita F, Giustetto C, Bianchi F, et al. Short QT syndrome: a familial cause of sudden death. Circulation 2003;108:965-970. https://doi.org/10.1161/01.CIR.0000085071.28695.C4
  5. Brugada J, Brugada R, Brugada P. Right bundle-branch block and ST-segment elevation in leads V1 through V3: a marker for sudden death in patients without demonstrable structural heart disease. Circulation 1998;97:457-460. https://doi.org/10.1161/01.CIR.97.5.457
  6. Antman E, Muller J, Goldberg S, et al. Nifedipine therapy for coronary-artery spasm: experience in 127 patients. N Engl J Med 1980;302:1269-1273. https://doi.org/10.1056/NEJM198006053022301
  7. Kimura E, Kishida H. Treatment of variant angina with drugs: a survey of 11 cardiology institutes in Japan. Circulation 1981;63:844-848. https://doi.org/10.1161/01.CIR.63.4.844
  8. Suzuki M, Nishizaki M, Arita M, et al. Increased QT dispersion in patients with vasospastic angina. Circulation 1998;98:435-440. https://doi.org/10.1161/01.CIR.98.5.435
  9. Parchure N, Batchvarov V, Malik M, Camm AJ, Kaski JC. Increased QT dispersion in patients with Prinzmetal's variant angina and cardiac arrest. Cardiovasc Res 2001;50:379-385. https://doi.org/10.1016/S0008-6363(00)00290-X
  10. Basso C, Corrado D, Marcus FI, Nava A, Thiene G. Arrhythmogenic right ventricular cardiomyopathy. Lancet 2009;373:1289-1300. https://doi.org/10.1016/S0140-6736(09)60256-7
  11. Haissaguerre M, Derval N, Sacher F, et al. Sudden cardiac arrest associated with early repolarization. N Engl J Med 2008;358:2016-2023. https://doi.org/10.1056/NEJMoa071968
  12. Priori SG, Wilde AA, Horie M, et al. HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes: document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013. Heart Rhythm 2013;10:1932-1963. https://doi.org/10.1016/j.hrthm.2013.05.014
  13. McKenna WJ, Thiene G, Nava A, et al. Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy: Task Force of the Working Group Myocardial and Pericardial Disease of the European Society of Cardiology and of the Scientific Council on Cardiomyopathies of the International Society and Federation of Cardiology. Br Heart J 1994;71:215-218. https://doi.org/10.1136/hrt.71.3.215
  14. Tikkanen JT, Junttila MJ, Anttonen O, et al. Early repolarization: electrocardiographic phenotypes associated with favorable long-term outcome. Circulation 2011;123:2666-2673. https://doi.org/10.1161/CIRCULATIONAHA.110.014068
  15. Takagi Y, Yasuda S, Takahashi J, et al. Importance of dual induction tests for coronary vasospasm and ventricular fibrillation in patients surviving out-of-hospital cardiac arrest. Circ J 2009;73:767-769. https://doi.org/10.1253/circj.CJ-09-0061
  16. Sasaki T, Niwano S, Kitano Y, Izumi T. Two cases of Brugada syndrome associated with spontaneous clinical episodes of coronary vasospasm. Intern Med 2006;45:77-80. https://doi.org/10.2169/internalmedicine.45.1404
  17. Nishizaki M, Fujii H, Ashikaga T, Yamawake N, Sakurada H, Hiraoka M. ST-T wave changes in a patient complicated with vasospastic angina and Brugada syndrome: differential responses to acetylcholine in right and left coronary artery. Heart Vessels 2008;23:201-205. https://doi.org/10.1007/s00380-007-1036-3
  18. Noda T, Shimizu W, Taguchi A, et al. ST-segment elevation and ventricular fibrillation without coronary spasm by intracoronary injection of acetylcholine and/or ergonovine maleate in patients with Brugada syndrome. J Am Coll Cardiol 2002;40:1841-1847. https://doi.org/10.1016/S0735-1097(02)02494-4
  19. Ong P, Bastiaenen R, Batchvarov VN, et al. Prevalence of the type 1 Brugada electrocardiogram in Caucasian patients with suspected coronary spasm. Europace 2011;13:1625-1631. https://doi.org/10.1093/europace/eur205
  20. Gussak I, Antzelevitch C. Early repolarization syndrome: clinical characteristics and possible cellular and ionic mechanisms. J Electrocardiol 2000;33:299-309. https://doi.org/10.1054/jelc.2000.18106
  21. Lellouche N, Sacher F, Jorrot P, et al. Sudden cardiac arrest: ECG repolarization after resuscitation. J Cardiovasc Electrophysiol 2011;22:131-136.
  22. Rosso R, Glikson E, Belhassen B, et al. Distinguishing "benign" from "malignant early repolarization": the value of the ST-segment morphology. Heart Rhythm 2012;9:225-229. https://doi.org/10.1016/j.hrthm.2011.09.012
  23. Takagi Y, Yasuda S, Tsunoda R, 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;4:295-302. https://doi.org/10.1161/CIRCEP.110.959809
  24. Kugiyama K, Yasue H, Okumura K, et al. Nitric oxide activity is deficient in spasm arteries of patients with coronary spastic angina. Circulation 1996;94:266-271. https://doi.org/10.1161/01.CIR.94.3.266
  25. Sueda S, Oshita A, Izoe Y, et al. A long-acting calcium antagonist over one year did not improve BMIPP myocardial scintigraphic imagings in patients with pure coronary spastic angina. Ann Nucl Med 2007;21:85-92. https://doi.org/10.1007/BF03033985
  26. Jain MK, Ridker PM. Anti-inflammatory effects of statins: clinical evidence and basic mechanisms. Nat Rev Drug Discov 2005;4:977-987. https://doi.org/10.1038/nrd1901
  27. Rosenson RS, Tangney CC. Antiatherothrombotic properties of statins: implications for cardiovascular event reduction. JAMA 1998;279:1643-1650. https://doi.org/10.1001/jama.279.20.1643
  28. Xu Z, Okamoto H, Akino M, Onozuka H, Matsui Y, Tsutsui H. Pravastatin attenuates left ventricular remodeling and diastolic dysfunction in angiotensin II-induced hypertensive mice. J Cardiovasc Pharmacol 2008;51:62-70. https://doi.org/10.1097/FJC.0b013e31815bb629
  29. Yasue H, Mizuno Y, Harada E, et al. Effects of a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, fluvastatin, on coronary spasm after withdrawal of calcium-channel blockers. J Am Coll Cardiol 2008;51:1742-1748. https://doi.org/10.1016/j.jacc.2007.12.049

Cited by

  1. Can documented coronary vasospasm be the smoking gun in settling the etiology of sudden cardiac death? vol.32, pp.5, 2017, https://doi.org/10.3904/kjim.2017.283
  2. Symptomatic Long QT Syndrome Coexisting with Asymptomatic Acetylcholine-induced Vasospasm vol.60, pp.13, 2017, https://doi.org/10.2169/internalmedicine.6475-20
  3. Inherited arrhythmia syndrome predisposing to sudden cardiac death vol.36, pp.3, 2017, https://doi.org/10.3904/kjim.2020.481