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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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