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Polymorphic Ventricular Tachycardia Due to Variant Angina Diagnosed on Holter Monitoring and Confirmed with Cold Pressor Test

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Polymorphic Ventricular Tachycardia Due to Variant Angina Diagnosed on Holter Monitoring and Confirmed with Cold Pressor Test Turk Kardiyol Dern Ars 2017;45(3):271–274 doi: 10.5543/tkda.2016.55874 271 CASE REPORT Polymorphic ventricular tachycardia due to variant angina diagnosed on Holter monitoring and confirmed with cold pressor test Holter monitörizasyonu ile teşhis edilen ve soğuk bası testi ile tasdik edilen varyant anjina nedenli polimorfik ventriküler taşikardi Semi Öztürk1, M.D., Tuğba Aktemur2, M.D., Muhsin Kalyoncuoğlu1, M.D., Gündüz Durmuş1, M.D., Mehmet Can1, M.D. 1Department of Cardiology, Haseki Training and Research Hospital, İstanbul, Turkey 2Department of Cardiology, Ersoy Hospitals Group, İstanbul, Turkey Summary– A 52-year-old man complaining of persistent re- Özet– Elli iki yaşındaki erkek hastaya inatçı ve gece tekrar- curring chest pain at night underwent coronary angiogram layan göğüs ağrısı nedeniyle başka bir merkezde koroner at another institution. Normal coronaries were observed anjiyografi yapılmış ve koroner arterleri normal bulunmuş, and he was discharged with muscle spasmolytic prescrip- hasta kas spazmı giderici ilaçlar ile taburcu edilmiş. Semp- tion. Since symptoms had continued, 24-hour Holter moni- tomları devam eden hastaya yapılan 24 saat Holter monito- toring was ordered at our facility and results revealed huge rizasyonunda dev ST yükselmesi ve polimorfik ventriküler ST elevation and polymorphic ventricular tachycardia. Cold taşikardi saptandı. Kateterizasyon laboratuvarında uygula- pressor test performed in catheterization laboratory also re- nan soğuk bası testi de polimorfik ventriküler taşikardi ile sulted in ventricular tachycardia. Nifedipine was prescribed sonuçlandı. Hastaya nifedipine başlandı ve Holter monito- and follow-up Holter monitoring revealed no further vaso- rizasyonu ile olaysız olarak takip edildi. Olgu sunumumuz spastic episodes. Utility of 24-hour Holter rhythm monitoring gece tekrarlayıcı göğüs ağrısı olan hastalarda 24 saatlik and cold pressor test in patients with recurrent chest pain at ritm holteri değerlendirmesinin ve soğuk bası testinin yara- night is demonstrated in this report. rını ortaya koymaktadır. iagnosis of vasospastic angina (VA) (variant, He described re- Abbreviations: DPrinzmetal angina) can be challenging, since it current episodes of ACh Acetylcholine typically depends on use of drugs, such as ergonovine burning type of pain COVADIS Coronary Vasomotion Disorders (ER) or acetylcholine (ACh), at time of diagnostic an- lasting for 5 min- International Study Group ECG Electrocardiography giography. Operators sometimes skip this procedure utes occurring every ER Ergonovine as result of unavailability of the drugs, which may re- night and intensity CPT Cold pressor test VA Vasospastic angina sult in misdiagnosis. Easily conducted tests, 24-hour of pain increasing Holter monitoring and cold pressor test (CPT), can in early morning. help the clinician diagnose VA. Presently described is Each episode of pain resolved itself without taking case of VA diagnosed by Holter monitoring and con- any medication. Coronary angiography performed firmed with CPT. 3 weeks earlier at another institution had revealed normal coronaries; however, pain had continued, CASE REPORT despite use of 8 mg of thiocolchicoside twice a day for 1 week as recommended upon discharge. He had A 52-year-old man presented at outpatient clinic no relevant history of disease or smoking. Physi- complaining of chest pain persisting for 3 months. cal examination was unremarkable. Electrocardi- Received: August 03, 2016 Accepted: October 14, 2016 Correspondence: Dr. Semi Öztürk. Haseki Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İstanbul, Turkey. Tel: +90 212 - 529 44 00 e-mail: [email protected] © 2017 Turkish Society of Cardiology 272 Turk Kardiyol Dern Ars A B Figure 1. Rhythm strips from 24-hour Holter monitoring showing (A) huge ST-segment elevation shortly after mid- night, and (B) spontaneously terminated episode of polymorphic ventricular tachycardia in the morning. ography (ECG) and treadmill exercise test findings ther classified VA into definitive and possible forms. were normal. Since it was night pain, 24-hour Holter Definitive VA is defined as: (i) nitrate-responsive an- monitoring was ordered. Results displayed gradual gina during spontaneous episodes and (ii) either tran- ST segment elevation leading to huge ST segment sient ischemic ECG changes during spontaneous epi- elevation (Figure 1a). Recurrent episodes of non- sodes or inducible coronary artery spasm criteria are sustained polymorphic ventricular tachycardia that all fulfilled. Suspected VA is defined as: (i) nitrate-re- terminated spontaneously were observed (Figure1b). sponsive angina during spontaneous episodes and (ii) The patient was taken into catheterization laboratory. either equivocal/unavailable ischemic ECG changes Coronary angiogram was normal. Since ER and ACh during spontaneous episode, and equivocal inducible were unavailable, we decided to perform CPT. Left coronary artery spasm criteria.[2] Judkins catheter was positioned in coronary artery to According to COVADIS definition, provocation visualize possible vasospasm. Huge ST segment el- test is not required in case of transient ECG changes evation occurred 30 seconds after patient’s left hand during nitrate-responsive episode, which confirms de- was immersed in ice water container and evolved finitive VA. However, when nitrate-responsiveness is into polymorphic ventricular tachycardia. Due to not documented or ECG changes are equivocal, fur- life-threatening arrhythmia, 100 mcg nitroglycerine ther provocative tests are suggested. ER and ACh are was urgently injected into catheter and the hand was widely used for this purpose. In a large study of 1508 removed from ice water. ST segment elevation re- selective spasm provocation tests, intracoronary ACh solved in a few seconds. Extended release nifedipine provoked spasms in 36.0% of patients, and intracoro- 30 mg twice a day was prescribed. Follow-up 24- nary ER induced spasms in 29.8% of patients.[3] Since hour Holter monitoring on third day ruled out further ER and ACh have different effects on coronaries, re- vasospastic episode. Regular Holter monitoring for 1 cently, sequential provocation tests with alternating year was uneventful. use of these 2 agents has been proposed to overcome limitations of standard provocation tests and increase DISCUSSION sensitivity.[4] Furthermore, in addition to providing VA was first described as rest angina and ST segment diagnostic accuracy, a recent study found association [1] between poorer prognosis and positive ER provoca- elevation. It most often occurs between midnight [5] and early morning hours. Coronary Vasomotion Dis- tion test after 24 months of follow up. orders International Study Group (COVADIS) pub- Initially used CPT, a powerful sympathetic stimu- lished international criteria with nitrate-responsive lus, to predict subsequent hypertension.[6] CPT-medi- angina as fundamental to diagnosis. COVADIS fur- ated sympathetic stimulation causes increase in blood Polymorphic ventricular tachycardia due to variant angina diagnosed on Holter monitoring and confirmed with CPT 273 pressure and heart rate, and thus increase in oxygen have additional episode of VA during 1-year follow- demand, which is compensated for with dilation of up. normal coronary arteries. On the contrary, however, Financial support CPT may result in paradoxical constriction in ath- erosclerotic coronaries.[7] Diabetic and hypertensive The authors received no financial support for the re- patients without coronary atherosclerosis may have search or authorship of this article. [8,9] impaired response to CPT. Due to its close rela- Conflict-of-interest issues regarding the authorship or tionship to endothelial dysfunction, CPT is a predic- article: None declared. tor of cardiovascular events.[9] Waters et al. compared sensitivity of exercise, cold pressor, and ER testing REFERENCES in provoking attacks of VA. They demonstrated that in patients with active VA, an attack can be provoked 1. Prinzmetal M, Kennamer R, Merliss R, Wada T, Bor N. An- gina pectoris. I. A variant form of angina pectoris; preliminary by ER in more than 90% of cases, by exercise in ap- report. Am J Med 1959;27:375–88. [CrossRef] proximately 30%, and by the cold pressor test in about [10] 2. Beltrame JF, Crea F, Kaski JC, Ogawa H, Ong P, Sechtem U, 10%. We performed cold pressor test in present et al. International standardization of diagnostic criteria for case in order to determine nitrate responsiveness and vasospastic angina. Eur Heart J 2015. [CrossRef] to confirm definitive VA diagnosis despite low sensi- 3. Sueda S, Kohno H, Fukuda H, Ochi N, Kawada H, Hayashi tivity of the test due to unavailability of ER or ACh. Y, et al. Clinical impact of selective spasm provocation tests: Rarely, VA can cause ventricular arrhythmia, syn- comparisons between acetylcholine and ergonovine in 1508 examinations. Coron Artery Dis 2004;15:491–7. [CrossRef] cope, or sudden cardiac death.[11] Although reperfu- 4. Sueda S, Miyoshi T, Sasaki Y, Sakaue T, Habara H, Kohno H. sion arrhythmia after resolution of ST elevation was Sequential spasm provocation tests might overcome a limita- suspected, amount of ST segment elevation may be tion of the standard spasm provocation tests. Coron Artery Dis [12] related to ventricular arrhythmia. Sympathetic 2015;26:490–4. [CrossRef] overactivity and vagal withdrawal may have impact 5. Shin DI, Baek SH, Her SH, Han SH, Ahn Y, Park KH, et al. on vasospastic episodes. Vasospasm may involve nor- The 24-Month
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