Jin Jifu, Xia Guang, Luo Yu, Cai Ying, Huang Ying, Yang Zhiyun, Yang Qinghui, Yang Bing
Department of Cardiology, School of Medicine, Shanghai East Hospital, Tongji University, Shanghai, China.
Front Cardiovasc Med. 2023 Mar 14;10:1145075. doi: 10.3389/fcvm.2023.1145075. eCollection 2023.
Coronary artery spasm (CAS) may induce lethal ventricular arrhythmia due to severe and prolonged vessel constriction. Tyrosine kinase inhibitors are associated with the occurrence of CAS. Optimal medical treatment is the first-line therapeutic option for the management of CAS, whereas patients who experienced aborted sudden cardiac death (SCD) may benefit from implantable cardioverter-defibrillator (ICD) implantation. We report a case of a 63-year-old Chinese man receiving tyrosine kinase inhibitor treatment for liver cancer who presented with recurrent chest discomfort and syncope with an elevation of high-sensitivity troponin T. Emergent coronary angiography showed sub-total occlusion of the left anterior descending artery without other signs of CAS. Percutaneous transluminal coronary angioplasty with a drug-coated balloon was performed successfully with the guidance of intravascular ultrasound. After 5 months, the patient returned to the emergency room for chest discomfort and another episode of syncope. The electrocardiogram showed ST-segment elevation in the inferior and V5-V6 leads compared to the previous event. Coronary angiography was repeated immediately and showed significant luminal stenosis at the midportion of the right coronary artery (RCA), whereas, after administration of intracoronary nitroglycerine, a remarkable recovery of RCA patency was noticed. A diagnosis of CAS was made, and soon after that, the patient rapidly developed ventricular arrhythmia in the coronary care unit. After successful resuscitation, the patient recovered completely and received long-acting calcium channel blockers as well as nitrates therapy. ICD implantation was performed considering the high risk of recurrence of life-threatening ventricular arrhythmia. During the follow-up period, the patient has been free of angina, syncope, or ventricular arrhythmia, and ICD interrogation showed no ventricular tachycardia or ventricular fibrillation. We first reported the case of a patient with CAS induced by regorafenib treatment complicated with severe atherosclerotic coronary disease who survived from sudden cardiac arrest. ICD implantation is indicated in patients who experienced aborted SCD for the prevention of the next lethal ventricular arrhythmia.
冠状动脉痉挛（CAS）可能由于严重且持续的血管收缩而诱发致命性室性心律失常。酪氨酸激酶抑制剂与CAS的发生有关。最佳药物治疗是CAS管理的一线治疗选择，而经历过心脏性猝死（SCD）未遂的患者可能受益于植入式心脏复律除颤器（ICD）植入。我们报告一例63岁中国男性，因肝癌接受酪氨酸激酶抑制剂治疗，出现反复胸痛和晕厥，高敏肌钙蛋白T升高。急诊冠状动脉造影显示左前降支次全闭塞，无其他CAS迹象。在血管内超声引导下成功进行了药物涂层球囊经皮冠状动脉腔内血管成形术。5个月后，患者因胸痛和再次晕厥返回急诊室。心电图显示与上次事件相比，下壁及V5-V6导联ST段抬高。立即重复冠状动脉造影，显示右冠状动脉（RCA）中段明显管腔狭窄，而在冠状动脉内给予硝酸甘油后，RCA通畅情况明显恢复。诊断为CAS，此后不久，患者在冠心病监护病房迅速发生室性心律失常。成功复苏后，患者完全康复，并接受长效钙通道阻滞剂以及硝酸盐治疗。考虑到危及生命的室性心律失常复发风险高，进行了ICD植入。在随访期间，患者未再出现心绞痛、晕厥或室性心律失常，ICD程控显示无室性心动过速或心室颤动。我们首次报告了一例由regorafenib治疗诱发CAS并合并严重动脉粥样硬化性冠状动脉疾病的患者，该患者从心脏骤停中存活。对于经历过SCD未遂的患者，建议植入ICD以预防下一次致命性室性心律失常。
