Long-term outcomes of a Caucasian cohort presenting with acute coronary syndrome and/or out-of-hospital cardiac arrest caused by coronary spasm

Abstract

BackgroundCoronary artery spasm may be the underlying mechanism in up to 10% of cases of acute coronary syndrome (ACS) and sudden cardiac death. Asian individuals exhibit a 3-times greater incidence of spasm than Caucasians; this is likely due to different types of mechanisms. Consequently, solid data is limited about the long-term prognosis in Caucasian patients presenting with ACS and/or out-of-hospital cardiac arrest (OHCA) caused by coronary spasm.MethodsBetween 2002 and 2015, thirty Caucasian patients with coronary artery spasm presenting with ACS (N = 29) and/or OHCA (N = 11) were enrolled in this prospective registry. Follow-up, consisting of regular outpatient visits, was conducted with a mean follow-up period of 7.5 ± 3.3 years. Outcomes included presence of stable angina pectoris, recurrence of ACS, occurrence of implantable cardioverter defibrillator (ICD) shocks and death.ResultsThe majority of patients (60%) remained asymptomatic during the entire follow-up period. At the end of the follow-up period only 3 patients still experienced stable angina (10%). Only 2 patients (7%) had a recurrent cardiac event, in which the ICD provided appropriate shock therapy. Half of the patients treated with stenting (N = 6), required re-interventions.ConclusionCoronary spasm with ACS and/or OHCA in a Caucasian patient cohort has a relatively benign prognosis in the majority of patients in long-term follow-up, if treated appropriately with medical therapy. Both the role of ICD in OHCA secondary to coronary spasm, and the efficacy of stenting to treat vasospastic angina, warrant further study in large-sized prospective clinical trials.

JCS/CVIT/JCC 2023 Guideline Focused Update on Diagnosis and Treatment of Vasospastic Angina (Coronary Spastic Angina) and Coronary Microvascular Dysfunction

“…Although there are not many reports on prognosis and ICD availability in VSA (Table 24), [475][476][477][478][479] a recent systematic review 480 found that at a mean follow-up of 4.2 years, 6% of patients with VSA died, and the mortality rate was higher in patients with ASCD compared to patients without a history of cardiac arrest (9% vs. 5%). Among the ASCD patients, those who underwent an ICD implantation, had a lower mortality rate than those who did not (3% vs. 14%), and appropriate ICD therapy was observed in 17% of patients.…”

Management of Coronary Artery Spasm

“…The recurrence of cardiac arrest/syncope caused by ventricular tachyarrhythmias after a single episode of cardiac arrest is unlikely in patients in whom both angina symptoms and ischaemic episodes, as well as CAS induced by provocation tests, are fully prevented by optimal medical therapy. [97][98][99][100] Thus, the indication for an ICD in these patients is questionable when also considering the potential issues related to device implantation, including the risk of inappropriate discharge and infection. Conversely, in patients in whom cardiac arrest occurs due to ventricular tachycardia/VF in the context of periods of refractory CAS or with CAS not well controlled by medical therapy (as indicated by the induction of CAS by provocation tests under optimal medical therapy), an ICD can be life saving and should therefore be implanted.…”

Myocardial infarction with non-obstructive coronary arteries: a focus on vasospastic angina

“…These patients should be treated with adequate pharmacotherapy, and physicians may consider ICD implantation for secondary prevention of cardiac arrest [ 47 ]. A recent study evaluated the long-term prognosis in Caucasian patients presenting with OHCA caused by coronary vasospasm [ 48 ]. All patients received a CCB or nitrates or both.…”