Multivessel Coronary Vasospasm With Aborted Sudden Death and Refractory Angina: Efficacy of Alpha-Blockers and Indication of Implantable Cardioverter-Defibrillator

Abstract

Vasospasm of the coronary arteries is an uncommon and underdiagnosed cause of angina pectoris. There is a myriad of clinical presentations with variable prognoses. The typical presentation in the scenario of chronic coronary syndrome includes angina at rest or with variable threshold, from late evening to early morning, including transient ischemia responsive to nitrates, detectable by 12-lead electrocardiogram or Holter. Concurrent multivessel vasospasm is rare and with worse prognosis, given the potential for acute ST-elevation myocardial infarction, ventricular arrhythmias and subsequent sudden cardiac death. The presence of refractory angina is a sign of persistent vasospasm, indicating severe manifestations. The complex physiopathology, including hypercontractility of the vascular smooth muscle, endothelial dysfunction and adrenergic receptor activation has not been fully elucidated, which makes it difficult to define a targeted therapy. We present a case of refractory angina after multivessel vasospasm with aborted sudden death, which responded to alpha-blocker and had implantable cardioverter-defibrillator implantation postponed.