A 40 years old female with proven RCA coronary vasospam leading to CHB and syncope who was doing extremely well on medical therapy with Amlodipine and Mononitrate. However she self terminated Amlodipine due to LE edema which was refractory to diuretic therapy. A couple weeks later she had similar recurrent episode with CHB which was confirmed again on ILR. Amlodipine has been resumed with no recurrent episode following several months. However the patient requested any other alternative than Amlodipine due to LE swelling.
Any role of PPM? PPM would prevent syncope but not possible MI.
Any role of percutaneous intervention? Or even 1 vessel CABG?
My only recommendation is to continue with current medical therapy that she has been doing well on except LE swelling. However it seems not the best option to the patient.
Any suggestion?
Hello
Except for cases with left anterior descending artery coronary artery and left main coronary artery stenosis, coronary artery by-pass graft is not performed for only the right coronary artery in your case. Percutaneous coronary procedures are also not recommended for vasospasm.
Other calcium channel blockers that have less leg edema and also antianginal activities, I recommend benidipine (twice a day), felodipine (fda approval), lercanidipine, nifedipine.
Permanent pacemakers are not recommended in such cases unless there are cases of complete blockade due to vasospasm resistant to medical therapy.
I have good results in coronary vasospasm with Verapamil, it causes much less leg edema.
Diuretics are not helpful in leg edema caused by calciumblockers.
Although Amlodipine is most commonly used drug for treating coronary vasospasm because of its good patient adheribility ( single dosing). But it's usual side effects like leg odema , restrict their use. option than Amlodipine is benidipine having high therapeutic index and fewer side effects like leg odema . There is no recommendation for CABG for RCA vasospasm unless LAD or Left main block. There is no role of PPM for Drug induced syncope unless permanently CHB. TPM may indicated symptoms not amenable to medical therapy.
Hello willy
In this case, the use of verapamil, a nondihydropyridine calcium channel blocker, is contraindicated because of the patient's complete atrioventricular block. Instead, dihydropyridine group calcium channel blockers other than amlodipine should be used.
Dear M. Karakayali,
I agree that verapamil and diltiazem are contraindicated in the case of CHB. But the CHB in this specific case is provoked by the ischemia of the AV node which is mostly fed by the right coronary artery. If spasm and ischemia is prevented by verapamil AV conduction should remain normal. In any case the patient must be treated with a calcium blocker as severe coronary spasm van be lethal.
In this Case CHB is due to RCA spasm leads to Ishaemia of Node so if Ishaemia is prevented chance of Ishaemia prevented
Certainly revascularizion is not an option for vasospasm if it occurs with out coronary plaque and very rarely CABG is a choice of revascularization in non LAD or LM lesions. It important to know if CHB is associated with angina. It will be also prudent to keep in mind about other causes of CHB which may coexist, and in those cases verapamil or diltiazem may be detrimental. To be precise on the question, I would go for a cardiac MRI. If there is no clue for syncope (other than the Ischaemia it self), I will go for verapamil or diltiazem. I truly appreciate, DearTheingi Tiffany Win, for your very thought provoking question.
Good to read all the responses and thanks everyone. I will look into benidipine (personally have never used it before) not even sure its available and will be covered by her insurance.
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