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CORONARY ARTERY SPASM WITHOUT SIGNIFICANT

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									                   CORONARY ARTERY SPASM WITHOUT SIGNIFICANT CORONARY HEART DISEASE IN A TEST PILOT
                         BROCQ F-X.1, PONS F.², POYET R.², MANEN O.3, DOIREAU Ph.4, GOMIS J-P.1, WELSCH G.1, GOMMEAUX H.1, CELLARIER G.2, B. SICARD1, MONTEIL M.1
                          (1) Aeromedical Military Center, Sainte-Anne Military Hospital Toulon, France                            (3) Aeromedical Military Center, Percy Military Hospital, Clamart, France
                          (2) Department of cardiology, Sainte-Anne Military Hospital, Toulon, France                              (4) Aeromedical Military Center, Robert Picqué Military Hospital, Bordeaux, France

Introduction : Coronary heart disease         Case report : A 53-yr-old test pilot (fighter and     Second and third coronary angiographies with                     Fig. 1 : LAD basis                                        Fig. 2 : LAD methergin
(CHD) and its modes of presentation,          business aircraft), with hyperlipidemia but non-      adapted treatment (calcium channel blockers)
sudden cardiac death, myocardial              smoker, describes a spontaneous early morning         show no reduction lumen vessels with MTG
infarction, ischemic arrhythmias, angina,     chest pain for 20 minutes. The diagnosis of ACS       testing, no symptoms and no EKG modification.
can provide sudden incapacitation or          is hold in front of the typical characteristics of    Furthermore, intra-vascular ultrasound (IVUS)
performance decrement. It is the reason       the pain despite normal electrocardiogram             on LAD confirms non significance of the stenosis
why CHD is one of the major topics in         (EKG) and cardiac enzymes. The first coronary         (minimal luminal area = 4,22 mm²).
aeronautical     medicine.     But      the   angiography shows a non significant CHD with          Finally, licensing authorities declare this pilot fit
management of coronary artery spasm           40% stenosis of left anterior descending (LAD)2       with a waiver, even for high performance
(CAS) among acute coronary syndrome           (Fig. 1). Provocation methylergometrine (MTG)         cockpit, with a second pilot on board. The timing
(ACS) is less explicit in current licensing   testing is processed and the diagnosis of CAS is      of revaluation is biannual. Regular graded
policies. We describe the management of       made on impressive reproduction of the                exercise testing with radionucleide perfusion
a “test pilot” with CAS presenting as         patient’s symptoms and reduction of the vessel        scintigraphy is scheduled in the follow-up.
unstable angina.                              lumen in LAD 2 (Fig. 2).

Discussion : ACS is suspected in patients with chest pain at rest             Possible pathophysiological factors involved in CAS are increased vasomotor        Conclusion : CAS is a not exceptional cause of spontaneous chest pain. In flying
associated with elevation of cardiac markers, ischemic                        tone, smooth muscle contraction, endothelial dysfunction, role of nitric oxide     personnel, it seems important to detect spasm as a possible mechanism of ACS.
electrocardiographic changes, or simply typical clinical symptoms             and phospholipase C, intracoronary mast cell activation but especially vagal       CAS is a variety of CHD which imposes, before fitness evaluation, a new coronary
of unstable angina. When coronary angiography is made, up to                  withdrawal and sympathetic activity (4), factors classically met in aeronautical   angiography with adapted treatment after the initial diagnosis. As general CHD,
30% have unobstructed coronary arteries or at least no culprit                activity. So, among pilots, intracoronary provocation testing in ACS without       waiver, if given, imposes second pilot on board and regular revaluation.
lesion that could explain the symptoms (1). Among such patients,              culprit lesion is of major importance. Once diagnosis made, checking of            References :
when they undergo intracoronary provocation testing, a coronary               absence of symptoms, EKG modification or reduction of the vessel lumen             (1) Yang HE and al Angina pectoris with normal coronary angiogram. Hertz 2005;30:17-25.
spasm is frequent (2). Furthermore, contrary that in Asian                    during a provocation test under adapted treatment is mandatory. Of course, if      (2) Ong P. and al. Coronary artery spasm as a frequent cause of acute coronary syndrome. J Am
population where CAS is well known, CAS in Caucasian                          present, cessation of smoking is compulsory. Furthermore, in such patients,        Coll Cardio 2008;52:523-27.
population seems to be underestimated : 49 % present a coronary               screening of non significant CHD by IVUS mainly evaluates the risk of major        (3) Pepine C. Provoked coronary spasm and acute coronary syndromes. J Am Coll Cadiol
                                                                                                                                                                 2008;52:528-30.
spasm (2). This underestimation may be due to the lack of testing             cardiovascular events. This risk is increased with a minimal luminal area of       (4) Stern S. and al. Coronary artery spasm. A 2009 update. Circulation 2009;119:2531-34.
to detect spasm as a possible mechanisms for ACS when other                   4mm² or less, a plaque burden of 70 % or greater or a classification as thin-cap   (5) Stone G. and al. A prospective natural-history study of coronary atherosclerosis. N Engl J Med.
causes are not apparent (3).                                                  fibroatheromas (5).                                                                2011;364/226-35.

								
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