ST-segment elevation myocardial infarction with refractory cardiogenic shock due to coronary spasm: a case report.

Background: Acute coronary syndrome (ACS) is primarily due to obstructive coronary artery disease (CAD). Nevertheless, in 1-14% of cases, ACS is present without evidence of obstructive CAD. Coronary artery spasm is an uncommon cause of ACS. Diagnostic work-up includes acute invasive coronary angiography and afterwards provocation testing. The optimal patient management is for patients presenting with cardiogenic shock due to ACS caused by coronary artery spasm is unclear. Case summary: A 67-year-old Caucasian, who underwent elective revision of hip arthroplasty, presented with ST elevations with circulatory collapse, leading to resuscitation due to anaesthesia induction. Extracorporeal membrane oxygenation (ECMO) implantation led to restoration of spontaneous circulation. Coronary angiography revealed coronary vasospasm, which was successfully treated with nitrates i.c. Later, despite of implanted ECMO, recurring haemodynamic deterioration required continuous administration of nitrates i.v., which finally resulted in the stabilization of circulatory system. Extracorporeal membrane oxygenation removal was possible 48 h after implantation and another 12 h later we extubated the patient. Furthermore, we administered calcium antagonists and an intra-cardiac defibrillator was implanted. Finally, the patient was discharged 12 days after admission with no physical or neurological restrictions after resuscitation. Discussion: This unique case highlights that rare causes of severe ACS with cardiogenic shock need to be considered. Administration of vasodilators, which are not part of the standard care in cardiogenic shock, represents the adequate treatment of a patient with spasm of coronary arteries. Furthermore, the recurrence of acute coronary events must be prevented by drug and device therapy in these patients.