Associazione Nazionale Medici Cardiologi Ospedalieri




Scordato Francesca Palermo(Palermo) – ARNAS Civico | Giunta Nicola Palermo(Palermo) – ARNAS Civico | Peritore Giuseppe Palermo(Palermo) – ARNAS Civico

We report the case of a 48-year-old female with a special history of ischemic heart disease.

It started in 2021 with an acute anterior ST myocardial infarction: the coronary angiography showed subocclusive stenosis at the first tract of the left anterior descending (LAD), without other coronary stenoses. The patient was treated with primary PCI + DES; the echocardiogram showed EF 30% and akinesia of apex, intermediate segments of anterior wall and interventricular septum. During the same hospitalization the patient experienced recurrence of angina with transient ST elevation in the anterior and inferior leads; a control coronary angiography was unchanged.

She was started on therapy with nitrates and diltiazem up to the tolerated dose, statin as well as antiplatelet and anticoagulant therapy due to apical thrombus. She underwent ICD implantation in primary prevention in January 2022.

During 2022, there were several accesses to the ED for vasospastic angina despite medical therapy at the maximum tolerated dose.

In October 2023 the patient experienced an acute chest pain followed by cardiac arrest, pulseless electrical activity and acute cardiogenic shock. After resuscitation procedures, she underwent an emergency coronary angiography which showed excellent result of the previous PCI, as well as stenosis of the distal edge of the stent resolving after injection of i.c. nitrates.

No arrhythmic events at ICD recording and continuous electrocardiographic monitoring in ICU were observed.

Cardiac MRI showed areas of subendocardial LGE involving the apex, anterior, anterolateral and septal segments due to ischemic scar; we also observed areas of edema and LGE with an ischemic pattern at the infero-septal and inferior wall in toto, suggesting recent ischemia; EF was 31%.

During hospitalization the patient experienced episodes of typical angina with poor response to medical therapy at the maximum tolerated dose.

The current clinical case most likely points to acute myocardial infarction due to vasospasm of the right coronary artery with acute pump failure resulting in cardiac arrest and no specific recommendations exist in recent cardiologic guidelines on the strategy to adopt for this acute clinical setting.

In the hypothesis of a vasospastic pathogenesis of the problem, counseling for modulation of the stellate ganglion was requested.