Cardiac arrest with coronary artery spasm: does the use of epinephrine during cardiopulmonary arrest exacerbate the spasm?

Coronary artery spasm can lead to sudden cardiac death due to ventricular arrhythmias or heart block. Cardiopulmonary resuscitation guidelines recommend the use of epinephrine during cardiopulmonary arrest. However, in the event of cardiac arrest caused by coronary artery spasm, the use of epinephrine may be harmful. We report 2 cases who had witnessed cardiac arrest due to ventricular fibrillation and complete heart block. Intravenous epinephrine was administered during resuscitation.Their hemodynamics did not improve. Emergent coronary angiography revealed that the entire right and left coronary artery systems diffuse spasm. One patient's coronary artery spasm was successfully reversed immediately with administration of intracoronary boluses of nitroglycerin. The other patient's hemodynamic instability persisted,requiring temporary mechanical circulatory support with an intra aortic balloon pump. His hemodynamics finally improved with administration of intravenous diltiazem and nitroglycerin under the intraaortic balloon pump support. They both were discharged from the hospital without any other complications.