Recurrent cardiac arrest and complete atrioventricular block due to idiopathic coronary vasospasm: A case report

Abstract

Recurrent complete atrioventricular block induced by coronary spasm is rare. We present a case of a 47-year-old woman who suffered from two episodes of out-of-hospital cardiac arrest within one year due to complete atrioventricular block caused by coronary vasospasm. No implantable cardioverter defibrillator was implanted after her first episode. As for the second episode, permanent brain injury was left behind despite successful cardiopulmonary resuscitation. She underwent a challenging rehabilitation process and an implantable cardioverter defibrillator was implanted before discharge. We captured the dynamic changes of the electrocardiogram during the episode with high temporal resolution. This case illustrates the importance of recognizing coronary spasm as a potential cause of complete atrioventricular block and highlights the need for implantable cardioverter defibrillator in such patients to improve survival and quality of life.

Keywords: Cardiopulmonary resuscitation; Case report; Complete atrioventricular block; Coronary spasm; Implantable cardioverter defibrillator.

Fig. 1

The patient's ECG changes during two episodes of illness. First episode: (A) Complete atrioventricular block and inferior ST-segment elevation (STE) at home (heart rate 45 bpm); (B) Sinus rhythm recovery after cardiopulmonary resuscitation (CPR), heart rate 73 bpm (precordial leads 1.25 mm/mV). Second episode: (C) Junctional escape rhythm at home (heart rate 32 bpm); (D) Junctional rhythm and inferior STE at the emergency department (heart rate 50 bpm) (precordial leads 5 mm/mV); (E) Sinus rhythm recovery after CPR, heart rate 73 bpm.

Fig. 2

Coronary angiography with different projection angles revealed normal left (A–D) and right coronary arteries(E-F).

Fig. 3

The patient had another life-threatening arrhythmia due to coronary spasm on day seven. (A) ECG (lead II) before cardiopulmonary resuscitation (CPR): (i) Sinus rhythm, 90 bpm (8:23 a.m.); (ii) Sinus rhythm with broad R waves (lambda wave), 94 bpm (8:24 a.m.); (iii) Sinus rhythm with broader and notched R waves, 94 bpm (8:25 a.m.); (iv) High-grade atrioventricular block (AVB), 68 bpm (8:26 a.m.); (v) Complete AVB, 34 bpm, no blood pressure (8:26 a.m., 33 seconds after iv-chart). Chest compression, adrenaline and atropine given. (B) ECG after CPR: (i) Lambda waves still present after 30 minutes of compression, with ST-segment elevation resembling nonischemic “action potential” or unusual “tombstone” (8:54 a.m.); (ii) Ventricular fibrillation (8:54 a.m.); (iii) Complete AVB after 150 J defibrillation (8:54 a.m.); (iv) First-degree AVB with atrial ectopy (8:55 a.m.); (v) Sinus tachycardia, 140 bpm (8:57 a.m.).

Fig. 4

Timeline of the case. CAS coronary artery spasm, CAVB complete atrioventricular block, CCU coronary care unit, CPR cardiopulmonary resuscitation, CRRT continuous renal replacement therapy, ICD Implantable cardioverter defibrillator.