We recently discussed the role of implantable cardioverter defibrillators (ICDs) as a complement to optimal medical management in patients with life-threatening ventricular arrhythmias (VAs) due to coronary artery spasm, in light of three cases managed in our department . As we stated, an ICD is not indicated in primary prevention in patients without a spasm-related life-threatening VA. However, the role of an ICD in secondary prevention after resuscitated sudden cardiac death due to vasospastic angina is unknown. Indeed, several cases reports have highlighted the risk of recurrent life-threatening VAs in such patients, despite optimal management (smoking cessation, non-dihydropyridine calcium channel blockers and/or nitrate derivatives ). Unfortunately, no clinical trial has been performed to provide definitive conclusions. We have proposed a cascade management strategy based on the results of an ergonovine test after the introduction of optimal medical treatment in such patients, to consider the implantation of an ICD . However, this proposition was based on clinical experience not on evidence-based medicine, which is currently the gold standard in modern cardiology.
In our previous review , we discussed the case of a 52-year-old woman who was initially managed for a first non-ST-segment elevation myocardial infarction with angiographically healthy coronaries and who presented 6 months later with a cardiac arrest treated by two shocks delivered by a semi-automatic defibrillator for ventricular fibrillation due to a recurrent coronary spasm, despite smoking cessation and optimal medical treatment (isosorbide mononitrate, calcium channel blockers, statin and aspirin). We decided to optimize her medical treatment (amlodipine, nicorandil, nifedipine, statin and dual antiplatelet therapy) and to implant an ICD. During the initial follow-up, the ICD interrogation showed several episodes of non-sustained ventricular tachycardia (maximum duration, 14 seconds).
During a recent face-to-face consultation, 36 months after ICD implantation, the patient described two episodes of dizziness without any context of stress or risk factors for coronary spasm (no cold environment, smoky atmosphere, etc.). Her medical treatment was unchanged, with perfect observance. The ICD interrogation showed two episodes of rapid ventricular tachycardia and ventricular fibrillation, well detected and successfully treated by antitachycardia pacing and one intracardiac shock (39.2 J) ( Fig. 1 ). This observation confirmed that the role of an ICD after life-threatening VA is important to define.
