Out of hospital cardiac arrest due to ventricular fibrillation with recurrent transient ST- segment elevation – OCT and FFR guided treatment decision in a severe case of vasospastic angina

Vasospastic angina is characterized by episodes of angina at rest with transient ST- segment elevation (STE) attributable to coronary spasm. In severe cases, malignant arrhythmias such as ventricular tachycardia (VT) and ventricular fibrillation (VF) can occur. Intracoronary imaging and functional testing have proven useful to diagnose and guide treatment in coronary artery disease. This case shows the application of optical coherence tomography (OCT) and fractional flow reserve (FFR) in the presence of moderate coronary artery disease and vasospastic angina. 

 

An 82-year-old male patient presented to the emergency department after out of hospital cardiac arrest (OHCA) due to VF with ROSC after 18 minutes. The electrocardiogram (ECG) upon arrival showed right bundle branch block. Echocardiogram revealed normal left ventricular systolic function without regional wall motion abnormalities. The coronary angiography showed a two-vessel disease with a 50-60% medial left anterior descending (LAD) and 80% distal circumflex (CX) stenosis (small vessel) with TIMI III flow. Therefore, a conservative treatment strategy was chosen. The patient was transferred to the intensive care unit (ICU) and a moderate temperature control (< 37°C over 5 days) was established. During the ICU stay recurrent transient STE were observed on the monitor (lasting only a few seconds) without a significant increase in cardiac hsTroponin levels. On day four the patient presented with persistent STE V1-V4. Due to known moderate LAD stenosis emergency coronary angiography was performed, revealing no significant new findings. OCT of the LAD revealed intima hyperplasia with eccentric calcified plaque in the medial LAD with a lumen reduction of 50-60%. Plaque rupture, dissection or thrombus material was ruled out. The FFR measurement performed showed no significant stenosis (FFR 0.85). 

At time of STE the echocardiogram showed normal systolic function without regional wall abnormalities. The STE were fully resolved within 60 minutes and there was no significant increase in cardiac hsTroponin levels.

Subsequently a conservative medical treatment with ASS, Statin, and a calcium antagonist in suspicion of vasospastic angina was decided upon. Under the above-mentioned treatment, the patient presented no further ECG changes or malignant cardiac arrhythmias. After extubation, the patient showed a good neurological outcome. Secondary prophylactic ICD implantation was performed a few days later. 

 

Conclusion:
This case shows a severe case of vasospastic angina in the presence of moderate coronary artery disease. Combing functional measurements (FFR) with intracardiac imaging (OCT) guided treatment decision making.