Ventricular fibrillation due to coronary vasospasm triggered by hyperventilation in a patient with panic disorder: case report.

Background: Panic attacks can trigger hyperventilation, which has been associated with the induction of coronary vasospasm. The resulting vasospasm may cause myocardial ischaemia and trigger life-threatening arrhythmias. Patients with panic disorders experiencing hyperventilation sometimes present with symptoms similar to those of acute coronary syndrome, making it difficult to determine their origin. Case summary: A 37-year-old man with a history of panic disorder was transported to our institute after he experienced hyperventilation during a panic attack and developed chest pain and a subsequent loss of consciousness. During transportation, ventricular fibrillation was observed on electrocardiography, and sinus rhythm was successfully restored with defibrillation. Suspecting hyperventilation-induced coronary vasospasm, a hyperventilation test was performed, which induced 90% coronary spasm accompanied by chest pain. An acetylcholine (ACh) provocation test revealed total occlusion of the left main bifurcation, with significant ischaemic ST-T elevation. Medication with a calcium channel blocker (nifedipine 40 mg per day), nitrate (isosorbide dinitrate 40 mg per day), and statin (rosuvastatin 20 mg per day) was initiated. Three months later, a repeat ACh provocation test performed to assess response to the medications revealed 90% stenosis with ischaemic ST-T changes and chest discomfort. Subsequently, a subcutaneous cardioverter defibrillator was implanted to address refractory vasospastic angina. Discussion: Herein, ventricular fibrillation was likely caused by coronary spasm induced by hyperventilation during the panic attack. Regarding the management of patients with panic disorder who present with chest pain, clinicians should carefully assess the symptoms and consider hyperventilation-induced coronary spasm as a differential diagnosis.