1. RCA Spasm and VF a case report Qi Zhang, MD Rui Jin Hospital Shanghai Jiao Tong University School of Medicine

2. Case information Female, 61y Brief history: chest discomfort in 2 weeks, with occurrence of syncope in last 4 days (twice). VF occurred in ER, rescued by electronic shock. Admitted with diagnosis of ACS on August 11, 2009. Coronary risk factors: none

3. After Admission… ACS regimen: ASA, Clopidogrel, Statins, Isoket, Betaloc, LMWH, etc. Lab findings: CK-MB 14.4ng/ml (NR:0.3~4.0), TnI 1.69ng/ml (NR:<0.04) LVEF: 0.51 She had re-occurrence of VF during hospitalization, and rescued by electronic shock and CRP, followed by anti- arrhythmia therapy.

4. Baseline EKG after Admission August 11, 2009

5. Hospital EKG Recording during VT and after Resuscitation

6. Coronary Angiogram 26h after admission

7. What we do… IV. GP IIb/IIIa inhibitor (tirofiban) Change to 6 JR 3.5 Guiding Catheter Preparing to perform PCI to RCA…

8. With Guiding Catheter

9. RCA Angiogram Comparison 1st with diagnositc catheter 2nd with guiding catheter

10. What to do ? What we did: Stop the procedure… Continuing with Tirofiban… IV. Using Calcium Channel Antagonist (Diltiazem 30mg q8h) Increase the dosage of statin (atorvastain 80mg) Add oral Nifedipine controlled-release tablet (adalat 30mg/d) Continue with ASA, Clopidogrel, LMWH, Nitrates…

11. With Intensive Anti-Spasm and Statins Therapy The patient was stable in the following 10 days. At day 12 after admission, PCI for LAD was performed.

12. CAG @ day 12

13. RCA Angiogram Replay 1st 2nd 3rd

14. PCI for LAD 6F JL 4.0 Guiding Runthrough wire 2.0x20mm balloon 3.5x13mm F2 stent 3.5x10mm balloon

15. Final Results

16. EKG after PCI August 24, 2009

17. Discharge Management Discharged on August 25, 2009 On Medications: ASA, Clopidogrel, Atorvastatin, Diltiazem, Nitrates. Intensive clinical follow-up, no MACE occurred.

18. Therapeutic Options in Coronary Spasm Cessation of smoking Obligatory Calcium antagonists The most commonly used drugs Long-acting nitrates Alone, or in combination with calcium antagonists Magnesium IV for acute therapy Oral supplementation for possible prevention Statins In addition to calcium antagonists To inhibit the RhoA-associated kinase pathway Percutaneous interventions If refractory to medical therapy, stent implantation may be successful Coronary bypass Success rate disputed Implantable defibrillator If life-threatening arrhythmias are documented Stern S. et al. Circulation 2009;119:2531

19. Take - Home Messages ACS/VF, coronary spasm may be the cause. Anti-spasm medication and intensive statins therapy should be considered in refractory ACS/VF patients. Early coronary invasive procedure should be performed in high-risk/electronic unstable ACS patients. Aggressive anti-arrhythmia devices/ICD should be avoided in those stable patients after revascularization and intensive medications.

20. Thanks