Ikebe So, Yamamoto Masahiro, Ishii Masanobu, Yamamoto Eiichiro, Tsujita Kenichi
Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto 860-8556, Japan.
Department of Medical Information Science, Graduate School of Medical Sciences, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto 860-8556, Japan.
Eur Heart J Case Rep. 2024 Sep 28;8(10):ytae540. doi: 10.1093/ehjcr/ytae540. eCollection 2024 Oct.
The concepts of myocardial infarction with non-obstructive coronary arteries (MINOCA) are now widely accepted. Calcium channel blockers (CCBs) are the first-line medication for coronary spastic angina (coronary spastic angina: CSA/vasospastic angina: VSA), while β-blockers sometimes do not improve CSA/VSA. However, β-blockers are essential for managing symptoms of coronary microvascular dysfunction and considered vital for treating heart failure with reduced ejection fraction (HFrEF).
We present the case of an 83-year-old female admitted with shortness of breath persisting for over 1 year and worsening ejection fraction (EF) from 65% to 32%. On admission, she experienced chest pain at rest despite finding no significant stenosis on coronary angiography. Several days later, we performed functional coronary angiography (FCA), revealing diffuse epicardial coronary spasm upon injecting acetylcholine. The coronary flow reserve was 4.4 (≧2.0), and the microvascular resistance index was 20 (<25). We diagnosed the patient with a myocardial injury event induced by CSA/VSA and initiated dihydropyridine CCBs. A few months later, her chest pain resolved; the HF symptoms improved (NYHA: from Ⅲ to Ⅱ), accompanied by a reduction in B-type natriuretic peptide levels (from 4561.2 to 75.4 pg/mL) and EF improvement (from 32.0% to 62.6%).
We managed a patient with HFrEF and MINOCA. Although CCBs are not routinely recommended for HFrEF, we added dihydropyridine CCBs to treat CSA/VSA based on comprehensive diagnostic procedures. This approach sedated chest pain and may have contributed to her EF improvement. Detailed examinations and tailored treatment strategies might be helpful for HF treatment.
非阻塞性冠状动脉心肌梗死（MINOCA）的概念现已被广泛接受。钙通道阻滞剂（CCB）是冠状动脉痉挛性心绞痛（冠状动脉痉挛性心绞痛：CSA/血管痉挛性心绞痛：VSA）的一线用药，而β受体阻滞剂有时并不能改善CSA/VSA。然而，β受体阻滞剂对于管理冠状动脉微血管功能障碍症状至关重要，并且被认为对治疗射血分数降低的心力衰竭（HFrEF）至关重要。
我们报告了一名83岁女性患者的病例，该患者因气短持续1年以上入院，射血分数（EF）从65%恶化至32%。入院时，尽管冠状动脉造影未发现明显狭窄，但她仍有静息胸痛。几天后，我们进行了功能性冠状动脉造影（FCA），注射乙酰胆碱后显示弥漫性心外膜冠状动脉痉挛。冠状动脉血流储备为4.4（≥2.0），微血管阻力指数为20（<25）。我们诊断该患者为CSA/VSA诱发的心肌损伤事件，并开始使用二氢吡啶类CCB。几个月后，她的胸痛消失；心力衰竭症状改善（纽约心脏协会心功能分级：从Ⅲ级降至Ⅱ级），同时B型利钠肽水平降低（从4561.2降至75.4 pg/mL），EF改善（从32.0%升至62.6%）。
我们治疗了一名患有HFrEF和MINOCA的患者。尽管CCB通常不被推荐用于HFrEF，但基于全面的诊断程序，我们加用二氢吡啶类CCB来治疗CSA/VSA。这种方法缓解了胸痛，可能有助于她的EF改善。详细的检查和量身定制的治疗策略可能有助于心力衰竭的治疗。
