Letter to the Editor
Recurrent syncope in a patient with vasospastic angina
Síncopes de repetición en un paciente con angina vasoespástica
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Ramos-Maqueda, Adrián Riaño Ondiviela, Cristina Navarro-Valverde" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Javier" "apellidos" => "Ramos-Maqueda" "email" => array:1 [ 0 => "javierramosmaqueda7@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Adrián" "apellidos" => "Riaño Ondiviela" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Cristina" "apellidos" => "Navarro-Valverde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Arritmias, Servicio de Cardiología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Arritmias, Servicio de Cardiología, Hospital Clínico Universitario Virgen de Valme, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síncopes de repetición en un paciente con angina vasoespástica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Vasospastic angina or Prinzmetal’s angina is an underdiagnosed pathology characterized by episodes of chest pain at rest and electrocardiographic abnormalities, mainly transient elevation of the ST segment, due to coronary vasospasm.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although this pathology can sometimes manifest itself with cardiogenic syncope in relation to atrioventricular blocks (AVB), these episodes are not always caused by bradyarrhythmias.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 54-year-old male smoker of 20 cigarettes a day, treated with acetylsalicylic acid (ASA) for a previous episode of amaurosis fugax. Two months after this episode, he consulted the emergency department for a 5 min angina with subsequent cardiogenic profile syncope while sitting on the sofa. Upon arrival at the hospital, the electrocardiogram (ECG) showed no signs of ischemia, the serum levels of ultrasensitive troponin T were within the normal range, and the echocardiogram showed no findings of interest. A coronary angiography was performed that did not reveal lesions in the coronary arteries. However, a few hours later, he had another episode of angina accompanied by presyncope. Telemetry monitoring showed signs of acute ischaemia and advanced AVB that subsided with sublingual nitrite administration, leading to a diagnosis of vasospastic angina. Despite quitting smoking and starting maximum doses of calcium antagonists and nitrates, the patient suffered a new episode of angina with advanced syncopal AVB, and it was decided to perform a permanent transvenous pacemaker implantation. At the first check-up after discharge, the patient continued to report some non-syncopal rest anginal episode accompanied by frequent palpitations. A 24 h Holter monitor documented high-density polymorphic ventricular extrasystoles (23% of heartbeats) without episodes of sustained ventricular tachycardia. Beta-blockers were not prescribed for such symptomatic extrasystoles as they are contraindicated in vasospastic angina. A few months later, he suffered a new episode of angina with subsequent loss of consciousness for which he returned to the emergency department, where, on arrival, while an ECG was being performed, he had another episode of chest pain accompanied by presyncope. On pacemaker examination, it was documented that the patient had experienced ventricular fibrillation (VF) during the first episode at home, so his pacemaker was upgraded to a dual-chamber cardioverter-defibrillator. The subsequent progression was favourable, although the patient continued with occasional angina and has required both cardiac pacing in 28% of his heartbeats and an appropriate shock for a new episode of VF.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Patients with vasospastic angina may experience syncope in association with bradyarrhythmias and even sudden cardiac death due to ventricular tachyarrhythmias.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> There is evidence of the benefit of the use of implantable cardioverter-defibrillators in patients with sudden cardiac death recovery<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>; however, there is no consensus on its use as primary prevention, so individualization of the risk in each case is recommended.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In this case, although the disease was potentially reversible with medical treatment, there were some factors that had been shown to be potentiating factors, such as ASA, which could not be discontinued due to the risk of a new episode of amaurosis fugax. Untreated oligosymptomatic ventricular extrasystoles due to the contraindication of beta-blockers in this disease could have acted as a precipitant of the VF episode, although it could also be directly caused by transient ischaemia in the context of coronary spasm. We therefore consider, after this case, that the existence of high-density ventricular extrasystoles in the 24 h Holter could be considered as a predictor of risk of sudden death in these patients and that, if they occur, other second-line antiarrhythmic treatments should be considered, as well as individualised consideration of the implantation of a cardioverter-defibrillator to avoid subsequent potentially lethal arrhythmic events.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0020" class="elsevierStylePara elsevierViewall">There are no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ramos-Maqueda J, Riaño Ondiviela A, Navarro-Valverde C. Síncopes de repetición en un paciente con angina vasoespástica. Med Clin (Barc). 2021;157:e351–e352.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Angina pectoris. I. A variant form of angina pectoris; preliminary report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M Prinzmetal" 1 => "R Kennamer" 2 => "R Merliss" 3 => "T Wada" 4 => "N Bor" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/0002-9343(59)90003-8" "Revista" => array:6 [ "tituloSerie" => "Am J Med" "fecha" => "1959" "volumen" => "27" "paginaInicial" => "375" "paginaFinal" => "388" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14434946" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Life-threatening arrhythmias leading to syncope in patients with vasospastic angina" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M Nishizaki" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.joa.2017.04.006" "Revista" => array:6 [ "tituloSerie" => "J Arrhythm" "fecha" => "2017" "volumen" => "33" "paginaInicial" => "553" "paginaFinal" => "561" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29255500" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Usefulness of implantable cardioverter-defibrillators in refractory variant angina pectoris complicated by ventricular fibrillation in patients with angiographically normal coronary arteries" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "SR Meisel" 1 => "A Mazur" 2 => "I Chetboun" 3 => "M Epshtein" 4 => "M Canetti" 5 => "J Gallimidi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0002-9149(02)02283-x" "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "2002" "volumen" => "89" "paginaInicial" => "1114" "paginaFinal" => "1116" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11988204" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coronary artery spasm and ventricular arrhythmias" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "KL Looi" 1 => "A Grace" 2 => "S Agarwal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/postgradmedj-2011-130494" "Revista" => array:6 [ "tituloSerie" => "Postgrad Med J" "fecha" => "2012" "volumen" => "88" "paginaInicial" => "465" "paginaFinal" => "471" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22438089" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015700000012/v1_202112201710/S2387020621006495/v1_202112201710/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015700000012/v1_202112201710/S2387020621006495/v1_202112201710/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621006495?idApp=UINPBA00004N" ]
