In May, 2012, a 46year-old woman reported chest pain before having an out-of-hospital cardiac arrest. Para medics successfully resuscitated her. The pre-arrest rhythm strip showed a sinus tachycardia only. A 12-h troponin I was raised at 5·9 μg/L (normal values 0–0·04 μg/L) A year earlier, she had been admitted with a similar history of chest pain, which had developed after taking sumatriptan for a migraine. A 12-lead electrocardiograph (ECG) showed transient inferior and lateral ST elevation. A 12-h troponin was negative. At this time, coronary angiography showed a normal left coronary system and a dominant right coronary artery, with minor ostial spasm and slow fl ow. A bubble study was negative for right to left shunting. She was diagnosed with vasospastic angina and started oral diltiazem. On advice, she stopped smoking and sumatriptan was discontinued. She continued to have occasional episodes of chest pain responsive to sublingual glycerol trinitrate. At the time of her cardiac arrest, her regular medications were oral diltiazem, nicorandil, lansoprazole, and a beclometasone inhaler. In the 48 h after the cardiac arrest she had fi ve additional pulseless electrical activity (PEA) arrests while intubated and ventilated in the intensive care unit. These were characterised by transient ST elevation (fi gure) and progressive hypotension, cul minating in loss of car diac output. Each episode responded to about 15–25 min of resuscitation. In between episodes, left ven tricular size and function was normal on echocardi ography. Electro cardiography was unremarkable. Repeat coronary angi ography showed normal coronary arteries, though of smaller luminal diameter than a year earlier. An intra-aortic balloon pump and a temporary tunnelled dual cham ber pacemaker were placed, which permitted potent vaso dilator therapy (intra venous glyceryl trinitrate and verapa mil, with nifedipine via a nasogastric tube) to be estab lished without the need for prolonged use of ino tropes. During this time, one episode of ST elevation and brady cardia was ter minated with a bolus of intravenous verapamil. The patient had a full neurological recovery; however it was complicated by the development of compartment syndrome in her left leg which necessitated removal of the intra-aortic balloon pump and a fasciotomy. She was converted to oral medications and underwent a cardiac magnetic resonance scan which was normal. At review in July, 2013, she remains entirely well. Although ventricular arrhythmia is recognised as the main cause of cardiac arrest in these patients, isolated cases of PEA have been reported. However, only one case has been described fully and did not feature the type of aggressive disease, with recurrent PEA arrests, detailed here. Patients with vasospastic angina are at higher risk of cardiac arrest than the background population. In a recent study of 1429 patients with vaso spastic angina, 35 (2·4%) had an out-of-hospital arrest and were younger (mean age 58 years) and more likely to have spasm of the left anterior descending coronary artery than were patients who had not had cardiac arrest. Since predicting which patients will have recurrent events is diffi cult, one suggestion is that all patients with vasospastic angina and a history of life-threatening arrhyth mia could benefi t from an automated implantable cardioverter-defi brillator alongside calcium channel blockers. In the absence of ventricular arrhythmias in our patient, an implantable cardioverter-defi brillator was not felt to be benefi cial. That this patient developed compart ment syndrome with no history of peripheral vascular disease is note worthy. We postulated that this was directly related to vasospasm provoked by the intra-aortic balloon pump. This case also highlights the value of intravenous calcium channel blockade to abort ST elevation and progression to PEA arrest. Our patient has been reminded to treat any further chest pain promptly with sublingual glyceryl trinitrate and seek immediate medical attention. Maintenance of vasodilator therapy has been strongly recommended. more...