CASE REPORT Multiple episodes of ventricular tachycardia induced by silent coronary vasospasm Ali Alizadeh Sovari & David Cesario & Abraham G. Kocheril & Ramon Brugada Received: 5 November 2007 / Accepted: 9 January 2008 / Published online: 23 February 2008 # Springer Science + Business Media, LLC 2008 Abstract We present a 46-year-old patient who suffered from cardiac arrest and subsequently underwent placement of an implantable cardioverter defibrillator (ICD). The patient underwent a cardiac catheterization which revealed no significant coronary artery disease. About 1 year later he experienced appropriated and frequent ICD discharges due to monomorphic ventricular tachycardia (VT) with left bundle branch block morphology. His prodromal symptoms were mild dizziness and lightheadedness with no chest pain. Amiodarone, mexiletine, sotalol and dofetilide as well as ablation of two inducible ventricular tachycardias in the electrophysiology studies were unsuccessful in controlling the arrhythmias and ICD discharges. During the last episode, he experienced a mild burning sensation in his chest and was given nitroglycerin 0.4 mg sublingually, which relived his symptoms and aborted the VT. This led to a second cardiac catheterization to investigate whether the VT was being induced by myocardial ischemia. This second coronary angiogram spontaneously revealed signif- icant coronary vasospasm and simultaneously, the patient’ s cardiac rhythm showed short runs of VT with left bundle branch block morphology. Intracoronary nitroglycerine relieved the coronary vasospasm and terminated the arrhythmia. The patient was treated with isosorbide mono- nitrate and diltiazem. He remained symptom free with no ICD discharges and no VT in ICD interrogations for more than 2 years. Coronary vasospasm may be silent and with no chest pain which creates a difficult clinical situation particularly if it is associated with ventricular tachycardia and sudden cardiac death. The mechanisms of VT in the setting of coronary vasospasm are not known and increased automaticity, focal discharges, functional unidirectional block with reentry, or a combination of these mechanisms may contribute to inducing the VT during the transient ischemia or rarely in the reperfusion phase. It is important to perform provocative tests to diagnose silent coronary vasospasm in unexplained sudden cardiac arrests. Keywords Ventricular tachycardia . Coronary vasospasm . Prinzmetal angina . Implantable cardioverter defibrillator . Ventricular arrhythmia . Sudden cardiac death 1 Case presentation A 46-year-old white male suffered from cardiac arrest and subsequently underwent placement of an implantable cardioverter defibrillator (ICD). The patient had no other significant medical history or family history of heart diseases. One year later he presented with a complaint of multiple ICD discharges due to monomorphic ventricular tachycardia (VT), with the shocks occurring predominantly early in the morning. He had some prodromal symptoms in the form of weakness and dizziness prior to the ICD discharges but no chest pain. During his earlier admission for cardiac arrest, the patient underwent a cardiac catheter- ization which revealed no significant coronary artery disease. The patient was initially successfully treated with amiodarone for a few months but ultimately experienced further ICD discharges. Mexiletine and sotalol were added to his medical regimen but were unsuccessful in controlling the arrhythmias and ICD discharges. J Interv Card Electrophysiol (2008) 21:223–226 DOI 10.1007/s10840-008-9207-4 A. A. Sovari (*) : D. Cesario : A. G. Kocheril : R. Brugada University of California, Los Angeles (UCLA), Los Angeles, CA, USA e-mail: asovari@mednet.ucla.edu