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Variant angina associated with myocardial bridging and obstructive sleep apnea syndrome after lumbar spine surgery.

Kang HY, Seo DY, Chung JY, Park SW, Kang JM - Korean J Anesthesiol (2014)

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Korea.

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Variant angina is caused by transient and recurrent coronary spasms leading to repetitive episodes of transmural myocardial ischemia... General anesthesia was induced with fentanyl 100 µg and propofol 120 mg with no abnormal cardiac symptoms or signs... The operation was performed successfully... Nitroglycerine infusion was increased to 1.0 µg/kg/min, and the ECG subsequently returned to normal sinus rhythm... After 10 minutes, the patient was fully awake and did not complain of chest pain... The standard cardiac markers were checked and were found to be within normal range... After consultation with a cardiologist, general anesthesia was induced again with slow injection of propofol 100 mg and infusion of nitroglycerine 1.0 µg/kg/min while monitoring patient's response and ECG changes closely... In the early postoperative period, the patient complained of intermittent chest pain with ECG revealing ST segment elevation in leads V1 to V3... Obstructive sleep apnea syndrome may be a predisposing factor for coronary spasm as a result of increased sympathetic activity during sleep... Repetitive cycles of hypoxia and reoxygenation increase reactive oxygen species and reduce the availability of endothelial nitric oxide, resulting in endothelial dysfunction, playing an important role in the pathogenesis of coronary spasms... After upper airway surgery, the patient complained of intermittent chest pain, and ST segment elevation was seen in leads V1-V3... ECG changes in leads V1-V3 seemed to be associated with myocardial bridging that was identified in the midsegment of the patient's left anterior descending coronary artery, as the territory supplied by the left anterior descending coronary artery corresponds with leads V1-V3... It is possible that these agents provoked coronary artery spasm via activation of the autonomic nervous system... In conclusion, we described a case of variant angina associated with myocardial bridging after a lumbar spine surgery.

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Coronary CT angiography reveals high-grade myocardial bridging (arrow) in the mid-segment of the left anterior descending coronary artery. (A) Coronal view, (B) axial view.
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Figure 1: Coronary CT angiography reveals high-grade myocardial bridging (arrow) in the mid-segment of the left anterior descending coronary artery. (A) Coronal view, (B) axial view.

Mentions: To determine the cause of these postoperative symptoms, several tests were performed. Levels of cardiac markers were analyzed (CK-MB: 0.6 ng/ml, Troponin I: < 0.01 ng/ml, Myoglobin: 12.7 ng/ml, BNP: 17 pg/ml) and were found to be normal. Twenty-four-hour Holter electrocardiogram (ECG) monitoring was performed, revealing subtle ST segment depression in the aVF lead. The patient also experienced chest discomfort at midnight. Coronary CT angiography revealed high-grade myocardial bridging at the mid-segment of the left anterior descending coronary artery (Fig. 1), which is known to have a 33% chance of abnormal diastolic contraction. Transthoracic echocardiogram revealed no regional wall motion abnormalities. The patient was diagnosed with variant angina and started on calcium channel blockers (diltiazem) 90 mg bid. The symptoms decreased in intensity and frequency, but intermittent chest pain persisted. The results of brain MRI were within normal limits, and no epileptiform discharges were seen in the electroencephalogram waking and sleep test. In the autonomic nervous system function test, normal responses were seen in the sympathetic skin response test for both hands and feet. Blood pressure and heart rate responses to postural changes were normal; however, abnormal variation was seen on heart rate variability analysis, which suggests dysfunction of the parasympathetic nervous system. On polysomnogram, sleep variables (apnea-hypopnea index [AHI]: 9.2/hr, respiratory disturbance index [RDI]: 18.1/hr, and arousal index: 27.8/hr) were found to be abnormal, and the patient was diagnosed with obstructive sleep apnea syndrome. His body weight and height were 88.8 kg and 1.77 m, respectively. The patient's body mass index was calculated to be 28.25 kg/m2.


Variant angina associated with myocardial bridging and obstructive sleep apnea syndrome after lumbar spine surgery.

Kang HY, Seo DY, Chung JY, Park SW, Kang JM - Korean J Anesthesiol (2014)

Coronary CT angiography reveals high-grade myocardial bridging (arrow) in the mid-segment of the left anterior descending coronary artery. (A) Coronal view, (B) axial view.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4295968&req=5

Figure 1: Coronary CT angiography reveals high-grade myocardial bridging (arrow) in the mid-segment of the left anterior descending coronary artery. (A) Coronal view, (B) axial view.
Mentions: To determine the cause of these postoperative symptoms, several tests were performed. Levels of cardiac markers were analyzed (CK-MB: 0.6 ng/ml, Troponin I: < 0.01 ng/ml, Myoglobin: 12.7 ng/ml, BNP: 17 pg/ml) and were found to be normal. Twenty-four-hour Holter electrocardiogram (ECG) monitoring was performed, revealing subtle ST segment depression in the aVF lead. The patient also experienced chest discomfort at midnight. Coronary CT angiography revealed high-grade myocardial bridging at the mid-segment of the left anterior descending coronary artery (Fig. 1), which is known to have a 33% chance of abnormal diastolic contraction. Transthoracic echocardiogram revealed no regional wall motion abnormalities. The patient was diagnosed with variant angina and started on calcium channel blockers (diltiazem) 90 mg bid. The symptoms decreased in intensity and frequency, but intermittent chest pain persisted. The results of brain MRI were within normal limits, and no epileptiform discharges were seen in the electroencephalogram waking and sleep test. In the autonomic nervous system function test, normal responses were seen in the sympathetic skin response test for both hands and feet. Blood pressure and heart rate responses to postural changes were normal; however, abnormal variation was seen on heart rate variability analysis, which suggests dysfunction of the parasympathetic nervous system. On polysomnogram, sleep variables (apnea-hypopnea index [AHI]: 9.2/hr, respiratory disturbance index [RDI]: 18.1/hr, and arousal index: 27.8/hr) were found to be abnormal, and the patient was diagnosed with obstructive sleep apnea syndrome. His body weight and height were 88.8 kg and 1.77 m, respectively. The patient's body mass index was calculated to be 28.25 kg/m2.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Korea.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Variant angina is caused by transient and recurrent coronary spasms leading to repetitive episodes of transmural myocardial ischemia... General anesthesia was induced with fentanyl 100 µg and propofol 120 mg with no abnormal cardiac symptoms or signs... The operation was performed successfully... Nitroglycerine infusion was increased to 1.0 µg/kg/min, and the ECG subsequently returned to normal sinus rhythm... After 10 minutes, the patient was fully awake and did not complain of chest pain... The standard cardiac markers were checked and were found to be within normal range... After consultation with a cardiologist, general anesthesia was induced again with slow injection of propofol 100 mg and infusion of nitroglycerine 1.0 µg/kg/min while monitoring patient's response and ECG changes closely... In the early postoperative period, the patient complained of intermittent chest pain with ECG revealing ST segment elevation in leads V1 to V3... Obstructive sleep apnea syndrome may be a predisposing factor for coronary spasm as a result of increased sympathetic activity during sleep... Repetitive cycles of hypoxia and reoxygenation increase reactive oxygen species and reduce the availability of endothelial nitric oxide, resulting in endothelial dysfunction, playing an important role in the pathogenesis of coronary spasms... After upper airway surgery, the patient complained of intermittent chest pain, and ST segment elevation was seen in leads V1-V3... ECG changes in leads V1-V3 seemed to be associated with myocardial bridging that was identified in the midsegment of the patient's left anterior descending coronary artery, as the territory supplied by the left anterior descending coronary artery corresponds with leads V1-V3... It is possible that these agents provoked coronary artery spasm via activation of the autonomic nervous system... In conclusion, we described a case of variant angina associated with myocardial bridging after a lumbar spine surgery.

No MeSH data available.


Related in: MedlinePlus