Significance of Coronary Artery Spasm Diagnosis in Patients With Early Repolarization Syndrome

Figures

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  Figure 1. At baseline, ECGs of a 42‐year‐old man in the early repolarization syndrome group exhibited J waves (arrows) followed by ascending ST segments in leads I, aVL, V4, and V5 in the standard (fourth) recording and in lead V2 in the second intercostal recording. After 50‐mg pilsicainide injection, all J waves in limb lead disappeared. In addition, saddleback ST elevation with slightly augmented J waves (broad arrows) were noted in V2 in the high (second and third) intercostal spaces.

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  Figure 2. A, ECGs of a 54‐year‐old man exhibited J waves in leads I, II, V5, and V6 (arrows). The patient experienced ventricular fibrillation during sleep in the absence of chest symptoms. B, No significant coronary stenosis was found in control coronary angiography before spasm provocation tests. C, Coronary artery spasm (CAS) was induced in the right coronary artery by intracoronary artery injection of ergonovine accompanied by chest pain. The patient was diagnosed as having silent CAS. LAO indicates left anterior oblique.

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  Figure 3. A, At baseline (left), ECGs of a 49‐year‐old man exhibited J waves ≧1 mm in leads V4, V5, and V6 (arrows) and J waves <1 mm in leads II, III, and aVF (broad arrows). ECGs during the spasm provocation test (middle) showed marked J‐wave augmentation in leads II, III, and aVF and ST elevation accompanied by QRS widening in leads V4 and V5 (arrows). These resolved after intracoronary infusion of isosorbide dinitrate (right). B, There were no significant stenotic lesions observed in both coronary arteries. C, After intracoronary injection of ergonovine, 99% stenosis was provoked in the left ascending artery (segment 7). During provocation of severe stenosis, the patient reported chest pain. CAU indicates caudal; and RAO, right anterior oblique.

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  Figure 4. A, ECGs from a 59‐year‐old man in the coronary artery spasm group showed notched J waves in leads III (1.1 mm) and aVF (1.0 mm) (arrows). The patient felt slight chest discomfort before the first ventricular fibrillation (VF). B, After admission to the hospital, nonsustained ventricular tachyarrhythmia associated with chest pain was observed in the monitoring ECG. Immediately before the onset of nonsustained ventricular tachyarrhythmia, ECGs showed dynamic J‐wave activity (5.8 mm) accompanied by notching and QRS widening (asterisks), which are consistent with typical electrocardiographic features before VF observed in previous studies of patients with early repolarization syndrome.

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  Figure 5. A, At baseline, ECGs of a 44‐year‐old man in the coronary artery spasm group exhibited J waves, followed by horizontal ST segments in leads II (1.4 mm) and aVF (1.7 mm) (arrows). B, ECGs 10 minutes before ventricular fibrillation (VF) showed slight augmentation of J waves and QRS widening in leads II (2.3 mm), III (2.0 mm), aVF (2.3 mm), and V6 (1.5 mm) (arrows). The patient complained of chest pain at that time. C, ECGs before VF showed marked J‐ST elevation and QRS widening in leads II (4.7 mm), III (6.3 mm), and aVF (5.7 mm), which are consistent with typical electrocardiographic features before VF observed in previous studies of patients with early repolarization syndrome.

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  Figure 6. Among 34 patients with idiopathic ventricular fibrillation (VF) and inferolateral J wave, 8 were diagnosed as having symptomatic coronary artery spasm (CAS) by spasm provocation test or spontaneous ST elevation. Of the remaining 26 asymptomatic patients with VF who might have been diagnosed as having early repolarization syndrome (ERS), 5 (19%) had silent CAS. ERS consisted of 9 patients with inferolateral and anterior J‐wave elevations and 12 patients with J‐wave elevations in the inferolateral leads only.

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  Figure 7. A, Kaplan‐Meier analyses of freedom from ventricular fibrillation (VF) during follow‐up in the early repolarization syndrome (ERS) and coronary artery spasm (CAS) groups. The incidence of VF during follow‐up was similar between the 2 groups. B, Kaplan‐Meier analyses of freedom from VF during follow‐up in the ERS, silent CAS, and symptomatic CAS groups. The incidence of VF during follow‐up was similar between the 3 groups.