2020 Scientific Sessions

Title

Hidden in Plain Sight: A case of paradoxical coronary vasospasm

Introduction

We present a case of paradoxical coronary vasospasm in a non-culprit artery while undergoing an intervention for an unstable lesion. The described patient developed shock thought to be cardiogenic in etiology given diffuse coronary vasospasm. After ruling out other etiologies such as perforation, coronary dissection and aortic dissection, the patient was found to have anaphylactic shock from contrast and had extensive truncal erythema and macular rashes. Anaphylactic shock however had presented with paradoxical coronary spasm which confounded the etiology of shock. Upon recognition, patient had marked improvement in hemodynamics after steroids, epinephrine and IV fluid administration. This presentation of “Kounis syndrome” or “allergic angina” or “allergic myocardial infarction” has been rarely described in the literature. Our case demonstrates real time occurrence and resolution of paradoxical coronary spasm with treatment of contrast anaphylaxis.

Clinical Case

A 56 year old gentleman with history of Hypertension and Diabetes mellitus presented with unstable angina. Physical exam, labs including troponin, and electrocardiogram were unremarkable. Patient underwent a SPECT myocardial perfusion imaging which showed reversible ischemia in the left anterior descending (LAD) territory and hence was referred for coronary angiogram. Diagnostic images revealed a 90% tubular stenosis in the proximal LAD. After crossing the lesion with a balanced middle weight (BMW) wire and subsequent balloon dilatation of the lesion, diffuse spasm was noted in the in the left circumflex (Lcx) and LAD. There was TIMI 0 flow in LAD and TIMI 2 flow in LCx. Patient became hypotensive with diaphoresis and developed severe chest pressure. Initial impression was possible balloon-mediated dissection of LAD and unclear etiology of Lcx spasm. Immediate stenting of the LAD with two drug-eluting stents was performed and patient was started on nor-epinephrine drip for hypotension. Subsequent angiograms showed fleeting nature of spasm in the Lcx, for which intravascular ultrasound (IVUS) was done to exclude any spiral dissection from left main. IVUS showed mild-moderate atherosclerotic disease in the Lcx, with no evidence of dissection. During an attempt to place a mechanical assist device, we noted diffuse erythema and macular rash on the trunk which suggested the shock to be anaphylactic in etiology. IV steroids and Diphenhydramine along with IV fluids were immediately given, with significant improvement in hemodynamics and patients symptoms.

Discussion

Kounis Syndrome is a rare entity which is characterized by spastic contraction of smooth muscle cells in the walls of coronary arteries, following exposure to an allergic stimulus. This is in contrast to typical cases of severe allergic reaction or anaphylaxis with vascular dilation and hyper-permeability. Three types of Kounis syndrome have been described based on presence of concomitant coronary disease. Given the propensity of coronary vasospasm, these patients often present with ST elevation on EKG and symptoms of chest pain and hemodynamics indicative of shock. This reversible etiology of coronary spasm should be considered for cases which are not clearly fitting of cardiogenic shock as the management is completely different.