Br Heart J: first published as 10.1136/hrt.35.6.601 on 1 June 1973. Downloaded from British Heart Journal, I973, 35, 60I-603.
Ventricular fibrillation in the course of Prinzmetal's angina pectoris Report of two cases
G. F. Levi and C. Proto From Spedali Civili di Brescia, Medicina Generale IVa Divisione-Gussago, Brescia, Italy
The presentation of 2 cases of ventricular fibrillation in a group of 7 patients with Prinzmetal's angina suggests that severe arrhythmia may be common with this type of coronary insufficiency. Clinically, a sequence of spontaneous anginal pain, palpitation, and syncope is suggestive of the syndrome; the electrocardiogram characteristically shows a monophasic ST-T wave which persists only for the duration of the episode. Patients suspected ofhaving this type of angina should be admitted to hospital and monitored in a coronary care unit, pending decision on an aortocoronary bypass operation. In the two cases observed by us, treatment with practolol (400 mg daily) was effective in abating both the anginal episodes and the ventricular arrhythmia.
The introduction of continuous electrocardiographic enabled two episodes of ventricular fibrillation to be monitoring has afforded the demonstration of epi- detected, which were successfully treated by elec- sodes of acute coronary insufficiency far more often trical defibrillation. http://heart.bmj.com/ than was previously possible. Some of these episodes differ from the normal Case reports electrocardiographic picture in that they show a Case i characteristic alteration of ST and T amounting to A 47-year-old man was in hospital, and gave a history of a single, monophasic wave; these are associated anginal episodes of 3 months' duration, sometimes after with a 'variant form of angina pectoris' often called exertion and sometimes at rest, becoming more frequent Prinzmetal's angina (Guazzi et al., I970; Meriel et in the last few weeks, particularly on awakening, lasting al., I966; Peretz, I96I; Prinzmetal et al., I959). In 3 or 4 minutes each, and accompanied by sweating and on October 2, 2021 by guest. Protected copyright. most patients of this description, coronary arterio- prostration. On admission the patient was free of pain; graphy reveals a single, circumscribed obstruction cardiac auscultation was noncontributory; heart rate was in one of the main coronary branches (Silverman 70/min; arterial blood pressure was I70/95 mmHg; and Flamm, I971). peripheral pulses were normal; the electrocardiogram was unremarkable. Clinically, Prinzmetal's angina occurs in the form Serum lipoprotein electrophoresis revealed a moderate of anginal episodes appearing spontaneously, not increase of the pre-3 fraction. All other blood chemistry triggered by physical exertion, usually of short findings were normal. duration, and associated with profuse sweating, The electrocardiogram of an anginal episode on the severe distress, and sometimes syncope (Dorra et al., second hospital day revealed a giant monophasic wave I968). in the right praecordial leads, disappearing in 2 to 3 According to Raynaud et al. (i969), 50 per cent minutes. On the fourth day the patient (now transferred of the patients with variant angina also present with to our cardiac monitoring unit) suffered an episode of severe alterations of cardiac and a sequence severe coronary pain radiating to the chest and jaws, rhythm; associated with profuse sweating. The electrocardio- of spontaneous pain, palpitation, and syncope must gram showed a monophasic wave in I, VL, with a be regarded as suggestive of Prinzmetal's angina. mirror image in II, III, and VF. While his cardiogram In our own experience, continuous monitoring of was being recorded, the patient developed ventricular a group of 7 patients with Prinzmetal's angina has fibrillation and fainted. A first attempt at defibrillation Received 30 October 1972. with IOO Joules was unsuccessful; the second attempt, Br Heart J: first published as 10.1136/hrt.35.6.601 on 1 June 1973. Downloaded from
6o2 Levi and Proto
with 300 joules, resolved the arrhythmia. Despite One hour after admission to the heart monitoring lignocaine perfusion and anticoagulant therapy, the unit, the patient had a further episode of chest pain. patient suffered several further episodes of anginal pain While the praecordial leads were being recorded, he in the next few days, always of the Prinzmetal type developed ventricular fibrillation with loss of conscious- and with bouts of ventricular extrasystoles which yielded ness (Fig. i); an electric shock Of 250 Joules restored to treatment only with practolol at a dose of 400 mg daily. sinus rhythm. Coronary arteriography, carried out two months later On his second and fourth hospital day, the patient at the Ospedale Policlinico San Matteo, University of developed repeated bouts of anginal pain, each lasting Pavia, revealed a proximally located, circumscribed 2. to 3 minutes, and associated with the appearance of a stenosis of the anterior descending coronary artery. monophasic wave in the praecordial leads. In spite of On 2. December I97I the patient underwent surgery lignocaine infusions, both ventricular extrasystole and (aortocoronary venous bypass) in the Department of atrial fibrillation (Fig. 2.) occurred repeatedly during the Surgery, University of Pavia. His postoperative course anginal episodes. On the fourth day treatment with was excellent, with complete freedom from anginal pain. practolol, 400 mg daily, was begun, which suppressed At the time of writing this paper, the patient continues anginal pain. to be asymptomatic and is able to undertake a fair The patient was discharged after 15 days, and was amount of physical activity. put on the waiting list for a coronary arteriography. But after a few days at home, without practolol, he died Case 2 suddenly, probably from ventricular fibrillation.
A 65-year-old man was admitted to hospital as an emergency because of prolonged anginal episodes. The Conclusions patient gave a two-month history of frequent praecordial In a group Of 7 patients in hospital between 969 pain, sometimes at rest, each episode lasting 4 or 5 and I971 with clinical evidence of Prinzmnetal's minutes and being associated with sweating, severe 2. ventricular distress, and momentary fainting. Clinical examination angina, patients developed fibrillation; of the cardiovascular system, as well as electrocardio- both were defibrillated electrically. In one of these grams, were essentially noncontributory. patients, coronary arteriography and subsequent http://heart.bmj.com/
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Ventricular fibrillation in the course of Prinzmetal's atngina pectoris 603
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FIG. 2 Case 2, Prinzmetal's angina with atrialfibrillation. http://heart.bmj.com/
V4vA 8t Guazzi, M., Fiorentini, C., Polese, A., and Magrini, F. (1970). operation confirmed the existence of a proximal Continuous in stenosis of the anterior descending*tcoronary. ~~~~~~~~~~. electrocardiographic recording Prinz- metal's variant angina pectoris. A report of four cases. A number of clinical and therapeutic considera- British Heart_Journal, 32, 6iI. tions emerge from these observations: Meriel, P., Galinier, F., Bounhoure, J. P., Mignon, J. P., and Prinzmetal's angina may often be accompanied by Salvador, M. (I966). Onde monophasique et tachycardie ventriculaire dans l'angor spontane de type Prinzmetal. episodes of ventricular arrhythmia (extrasystole and on October 2, 2021 by guest. Protected copyright. Archives des Maladies du Coeur et des Vaisseaux, 59, 460. ventricular fibrillation). Consequently, patients Peretz, D. I. (I96I). Variant angina pectoris of Prinzmetal. with variant angina should be admitted to a heart Canadian Medical Association Journal, 85, I IOI. monitoring unit. Prinzmetal, M., Kennamer, R., Merliss, R., Wada, T., and Beta-adrenergic blocking agents appear to be Bor, N. (I959). Angina pectoris I. A variant form of therapeutically effective, anginal pain and arrhyth- angina pectoris. American Journal of Medicine, 27, 375. Raynaud, R., Brochier, M., Morand, P., Fauchier, J. P., mia being controlled in both our cases with Raynaud, P., and Chatelain, B. (I969). Une forme clinique practolol. de l'angine de poitrine: l'angor de Prinzmetal. Semaine des Aortocoronary venous bypass apparently repre- Hopitaux de Paris, 45, 2662. sents the correct surgical procedure for these Silverman, M. E., and Flamm, M. D. (I97I). Variant angina patients. pectoris. Anatomic findings and prognostic implications. Annals of Internal Medicine, 75, 339. References Dorra, M., Waynberger, M., Nezry, R., and Slama, R. (I968). A propos d'une observation d'angor dit de Prinzmetal a Requests for reprints to Dr. G. F. Levi, Spedali Civili di forme syncopale. Etude coronarographique. Archives des Brescia, Medicina Generale IVa Divisione-Gussago, Maladies du Coeur et des Vaisseaux, 6I, 1043. 25064 Gussago, Brescia, Italy.