Arrhythmias in variant angina pectoris. Relationship of arrhythmias to ST-segment elevation and R-wave changes.

Abstract

SUMMARY Twenty-six patients with variant angina pectoris (VAP) were studied 1) to determine whether the degree of ST-segment elevation and R-wave changes correlate with the development of arrhythmias; and 2) to evaluate the relationship between the prevalence of arrhythmias, the severity of coronary artery disease, left ventricular function and wall motion.Serious arrhythmias were found in 12 patients (46%) (ventricular fibrillation in two, ventricular tachycardia in four, ventricular premature complexes [VPCs] [> 5 VPCs/min, multifocal and R-on-T phenomenon] in four, and second-and third-degree atrioventricular block in three). All twelve patients with arrhythmias had ST-segment elevation > 0.4 mV during VAP (range 0.4-1.6 mV). R-wave amplitude was compared before and during episodes of VAP and expressed as %AR. An increase in R 10% was seen in 10 of 12 patients with arrhythmias (group 1) and in only six of 14 patients without arrhythmias (group 2) (p < 0.05).Twenty-three of the 26 patients underwent coronary angiography and ventriculography, and one was examined by autopsy. Sixteen patients in this group had single or multiple high-grade obstructive lesions, while the remaining eight had normal coronary arteriograms.Arrhythmias were more common in the group with coronary obstructive disease (66%) than in the group with normal coronary arteriograms (44%). There was no significant difference between patients with arrhythmias (group I) and those without arrhythmias (group 2) in the coronary arteriographic score or left ventricular ejection fraction.The data suggest that arrhythmias occur frequently during VAP and correlate well with the degree of STsegment elevation and %AR. In patients with VAP, arrhythmias are not contingent upon preexisting coronary artery disease or left ventricular ejection fraction, and are more commonly detected in patients with normal coronary arteriograms. IN 1959 and1960, Prinzmetal et al.' 2 delineated a variant form of angina pectoris (VAP) that primarily differs from Heberden's classic angina pectoris in that the pain is frequently spontaneous, occurs at rest, and is unrelated to physical activity or emotion. The pain in VAP generally lasts longer and may be more severe than in classic angina pectoris. Attacks tend to be cyclic, often recurring at a specific time of day. Episodes of pain are accompanied by transient STsegment elevation with reciprocal changes in the standard leads, as opposed to typical ST-segment depression. VAP has been reported3-7 in patients with normal coronary arteriograms,1 2, 8 as well as in those with angiographically demonstrated focal lesions that affect the proximal segment of the coronary arteries.Abnormalities of rhythm and conduction may be associated with VAP.6 16 During pain, the wide spectrum of reported arrhythmias includes second-and third-degree atrioventricular block,6' 7, 9, 10 ventricular tachycardia and ventricular fibrillation,10' 11 ventricular premature complexes (VPCs),13' 14 ventricular asystole'5 and atrial fibrillation. 16 We studied ...

Ventricular fibrillation related to coronary spasm in patients without significant coronary or other structural heart disease

“…Ventricular arrhythmias are found in up to 50% of patients with documented coronary spasms and may be attributed to either vascular occlusion or reperfusion [14]. The incidence of ventricular arrhythmias is correlated with the severity of ischemia (duration and extent of ST elevations) but does not seem to be influenced by the site of ischemia, the presence or extent of fixed coronary stenoses, left-ventricular function, or the patient's age or sex [7,10].…”

“…Treatment with calcium antagonists and organic nitrates has been recommended in patients with coronary spasm [18] as well as in those with spasminduced arrhythmias [3,7,9,19]. However, recommendations have not yet been made as to dosage and alternative treatments, and comparative studies are lacking because of the small number of patients.…”

Diurnal distribution of ST-segment elevation and related arrhythmias in patients with variant angina: a study by ambulatory ECG monitoring.

“…[1][2][3] To our knowledge, however, no quantitative data have been reported on the diurnal distribution of ischemic episodes, such as chest pain and ECG changes, in variant angina except for a preliminary report by Kuroiwa,4 which showed a higher frequency of recurrent ST-segment elevations early in the morning. It is important to clarify the diurnal distribution of the episodes for the evaluation of pathophysiology of variant angina as well as for treatment.…”

Electrophysiology of coronary reperfusion. A mechanism for reperfusion arrhythmias.

“…1 Furthermore, in a recent review of the arrhythmias which accompany coronarv artery spasm, Kerin et al (23,24) noted that the arrhythmias freQuently occurred at a time when the ischemia induced ST segment elevation was beginning or had completely normalized. Thus, these authors concluded that some of these arrhythmias may have resulted from a reperfusion mechanism.…”