Dataset Information

A case report of dipyridamole stress-induced ST depression progressing to ST-elevation myocardial infarction despite intravenous aminophylline: steal, spasm, or something else?

ABSTRACT:

Background

Dipyridamole stress is commonly used for myocardial perfusion imaging and is generally safe. Myocardial ischaemia can occasionally occur and is classically thought to be due to coronary steal as a result of redistribution of flow away from collateral dependent myocardium. Although ischaemia more commonly presents as electrocardiographic (ECG) ST depression and angina, ST-elevation myocardial infarction may occur as a very rare complication.

Case summary

We report a case of a patient who developed chest pain and ST depression during dipyridamole infusion. The pain persisted despite intravenous aminophylline with new inferior ST elevation soon after. Coronary angiography showed subtotal right coronary artery occlusion with no collateral supply. The symptoms and ECG changes resolved after percutaneous coronary intervention.

Discussion

Coronary steal may not fully account for our patient's presentation given the failure of aminophylline and absent angiographic collaterals. Vasospasm may be triggered by dipyridamole and can directly cause ischaemia or provoke rupture of an unstable plaque. Augmentation of cardiac energetics during vasodilator stress may also play a role.

SUBMITTER: Li KFC

PROVIDER: S-EPMC6601234 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

A case report of dipyridamole stress-induced ST depression progressing to ST-elevation myocardial infarction despite intravenous aminophylline: steal, spasm, or something else?

Li Ki Fung Cliff KFC Ho Hee Hwa HH Yew Min Sen MS

European heart journal. Case reports 20190601 2

<h4>Background</h4>Dipyridamole stress is commonly used for myocardial perfusion imaging and is generally safe. Myocardial ischaemia can occasionally occur and is classically thought to be due to coronary steal as a result of redistribution of flow away from collateral dependent myocardium. Although ischaemia more commonly presents as electrocardiographic (ECG) ST depression and angina, ST-elevation myocardial infarction may occur as a very rare complication.<h4>Case summary</h4>We report a case ...[more]

PMID: 31449606

Similar Datasets

Project description:Background Adenosine is used to treat no-reflow in the infarct-related artery (IRA) during ST-segment-elevation myocardial infarction intervention. However, the physiological effect of adenosine in the IRA is variable. Coronary steal-a reduction of blood flow to the distal coronary bed-can occur in response to adenosine and this is facilitated by collaterals. We investigated the effects of adenosine on coronary flow reserve (CFR) in patients presenting with ST-segment-elevation myocardial infarction to better understand the physiological mechanism underpinning the variable response to adenosine. Methods and Results Pressure-wire assessment of the IRA after percutaneous coronary intervention was performed in 93 patients presenting with ST-segment-elevation myocardial infarction to calculate index of microvascular resistance, CFR, and collateral flow index by pressure. Modified collateral Rentrop grade to the IRA was recorded, as was microvascular obstruction by cardiac magnetic resonance imaging. Coronary steal (CFR <0.9), no change in flow (CFR=0.9-1.1), and hyperemic flow (CFR >1.1) after adenosine occurred in 19 (20%), 15 (16%), and 59 (63%) patients, respectively. Patients with coronary steal had higher modified Rentrop score to the IRA (1 [0, 1.75] versus 0 [0, 1], P<0.001) and a higher collateral flow index by pressure (0.25±0.10 versus 0.15±0.10, P=0.004) than the hyperemic group. The coronary steal group also had significantly higher index of microvascular resistance (61.68 [28.13, 87.04] versus 23.93 [14.67, 37.00], P=0.006) and had more disease (stenosis >50%) in the donor arteries (52.63% versus 22.03%, P=0.02) than the hyperemic group. Conclusions Adenosine-induced coronary steal may be responsible for a reduction in coronary flow reserve in a proportion of patients presenting with ST-segment-elevation myocardial infarction. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03145194. URL: https://www.isrctn.com; Unique identifier: ISRCTN3176727.

Project description:CONTEXT:Acute ST-segment elevation myocardial infarction (STEMI) is a leading cause of morbidity and mortality. In experimental models of MI, erythropoietin reduces infarct size and improves left ventricular (LV) function. OBJECTIVE:To evaluate the safety and efficacy of a single intravenous bolus of epoetin alfa in patients with STEMI. DESIGN, SETTING, AND PATIENTS:A prospective, randomized, double-blind, placebo-controlled trial with a dose-escalation safety phase and a single dose (60,000 U of epoetin alfa) efficacy phase; the Reduction of Infarct Expansion and Ventricular Remodeling With Erythropoietin After Large Myocardial Infarction (REVEAL) trial was conducted at 28 US sites between October 2006 and February 2010, and included 222 patients with STEMI who underwent successful percutaneous coronary intervention (PCI) as a primary or rescue reperfusion strategy. INTERVENTION:Participants were randomly assigned to treatment with intravenous epoetin alfa or matching saline placebo administered within 4 hours of reperfusion. MAIN OUTCOME MEASURE:Infarct size, expressed as percentage of LV mass, assessed by cardiac magnetic resonance (CMR) imaging performed 2 to 6 days after study medication administration (first CMR) and again 12 ± 2 weeks later (second CMR). RESULTS:In the efficacy cohort, the infarct size did not differ between groups on either the first CMR scan (n = 136; 15.8% LV mass [95% confidence interval {CI}, 13.3-18.2% LV mass] for the epoetin alfa group vs 15.0% LV mass [95% CI, 12.6-17.3% LV mass] for the placebo group; P = .67) or on the second CMR scan (n = 124; 10.6% LV mass [95% CI, 8.4-12.8% LV mass] vs 10.4% LV mass [95% CI, 8.5-12.3% LV mass], respectively; P = .89). In a prespecified analysis of patients aged 70 years or older (n = 21), the mean infarct size within the first week (first CMR) was larger in the epoetin alfa group (19.9% LV mass; 95% CI, 14.0-25.7% LV mass) than in the placebo group (11.7% LV mass; 95% CI, 7.2-16.1% LV mass) (P = .03). In the safety cohort, of the 125 patients who received epoetin alfa, the composite outcome of death, MI, stroke, or stent thrombosis occurred in 5 (4.0%; 95% CI, 1.31%-9.09%) but in none of the 97 who received placebo (P = .04). CONCLUSIONS:In patients with STEMI who had successful reperfusion with primary or rescue PCI, a single intravenous bolus of epoetin alfa within 4 hours of PCI did not reduce infarct size and was associated with higher rates of adverse cardiovascular events. Subgroup analyses raised concerns about an increase in infarct size among older patients. TRIAL REGISTRATION:clinicaltrials.gov Identifier: NCT00378352.

Dataset Information

A case report of dipyridamole stress-induced ST depression progressing to ST-elevation myocardial infarction despite intravenous aminophylline: steal, spasm, or something else?

Background

Case summary

Discussion

Publications

A case report of dipyridamole stress-induced ST depression progressing to ST-elevation myocardial infarction despite intravenous aminophylline: steal, spasm, or something else?

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure