Coronary artery spasm is a sudden and intense vasoconstriction of single-or multi-vessel coronary artery. It may be triggered by several acute stress. This case reports 72-year-old male with salbutamol inhalation suffer fatal multi-vessel coronary artery spasm. After intracoronary administration of nitroglycerin, coronary artery spasm was relieved. It reminds us to be cautious of β-agonist administration in respiratory patients with coronary artery spasm risk.
Coronary artery spasm (CAS) is one of the important functional cardiac disorders referred to a sudden and intense vasoconstriction of single-or multi-vessel coronary artery [1,2]. And it is well known to be associated to stable angina, acute coronary syndrome, even cardiac sudden death [3-5]. However, coronary angiography also showed that CAS not only occurred at the site of a stenosis (either minor or severe) but also in angiographically normal coronary arteries [5]. Although the causes and the mechanisms of CAS are still not revealed, inflammation, oxidative stress and autonomic nervous system have catch some truth [6-8].
Case Report
In our report, a 72-year-old male, a chronic smoker with history of hypertension and COPD (chronic obstructive pulmonary disease), firstly presented with shorten of breath in Respiratory Department by history and CT image diagnosis as shown in Figure 1. After accepting salbutamol inhalation therapy, patient had a sudden chest pain, progressive low blood press and shock. There was showed a fast sinus rhythm with marked depression of ST-T segment in V2-V5 chest leads by electrocardiogram (ECG) (Figure 2A). Cardiac troponin I, creatine kinase and lactate dehydrogenase level were significantly elevated confirming myocardial injury and death. Patient was received urgently oral treatment of aspirin 300 mg, clopidrogel 600 mg, and atorvastatin 40 mg before CAG (coronary angiography) operation. Emergency CAG showed widely spasm of left anterior descending (LAD), left circumflex (CIRC) arteries and right coronary artery (RCA) as shown in Figure 3. After intracoronary administration of nitroglycerin, coronary artery spasm was relieved. LAD, CIRC and RCA were appeared bigger in calibre and were non-obstructive in Figure 3.
Figure 1: Patient presented lung infection and COPD symptom signal by CT screening.
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Figure 2: Patient's ECG change. A) patient presented chest pain before PCI operation; B) patient's chest pain was relieved after nitroglycerin injection.
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Figure 3: Coronary angiographies before and after intracoronary administration of nitroglycerin. Widely coronary artery spasm presented before intracoronary nitroglycerin injection in A1 and B1. After intracoronary nitroglycerin injection, coronary artery spasm was relieved in A2 and B2.
View Figure 3
Discussion
Inflammation and autonomic nervous system play some roles in coronary artery spasm. Some inflammatory stimulus, such as interleukin-1β, serotonin and histamine could induce vascular smooth muscle cells hyperreactivity which is the key abnormality responsible for CAS [9-12]. Also, inflammation is a demonstrated pathophysiological basis of COPD [13]. Interleukin-1β, serotonin and histamine show a high levels in COPD patients [14,15].
The adverse effects of salbutamol (β-agonist reagent) are tachycardia, arrhythmia, and even myocardial ischemia [16]. But the effect of autonomic nervous system on CAS is complex. β-blockers may exacerbate angina attacks in patients with variant angina [17].
Conclusion
In summary, CAS is at the site of coronary stenosis or in angiographically normal coronary arteries. It may be triggered by emotional stress, cold exposure, and stimulant drugs such as amphetamines and cocaine. But it is rare a case of multi-vessel coronary artery spasm induced by β-agonist inhalation. As illustrated by our case, it must be cautious of β-agonist administration in respiratory patients with coronary artery spasm risk.
Declaration of Conflicting Interests
The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Conflict of Interest
The authors state no conflict of interest.
Acknowledgement
The authors disclose receipt of the following financial support for the research, authorship, and/or publication of this article: Supported by the National Natural Science Foundation of China (Grant No. 81300115) to Liang Shao.
Figure 1: Patient presented lung infection and COPD symptom signal by CT screening.
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Figure 2: Patient's ECG change. A) patient presented chest pain before PCI operation; B) patient's chest pain was relieved after nitroglycerin injection.
View Figure 2
Figure 3: Coronary angiographies before and after intracoronary administration of nitroglycerin. Widely coronary artery spasm presented before intracoronary nitroglycerin injection in A1 and B1. After intracoronary nitroglycerin injection, coronary artery spasm was relieved in A2 and B2.
View Figure 3