Beyond idiopathic ventricular fibrillation: Vasospastic angina uncovered after ICD implantation

Abstract

A woman in her 40s presented with epigastric pain and subsequently developed ventricular fibrillation (VF) cardiac arrest requiring resuscitation. The initial coronary angiography (CAG) revealed no significant stenosis. Due to limited resources and the unavailability of a provocation test, the patient was diagnosed with idiopathic VF, and an implantable cardioverter-defibrillator (ICD) was placed. Despite experiencing epigastric pain for two years with no significant endoscopic findings, an exercise stress test (EST) later identified ventricular arrhythmia, which suggested an ischemia-related mechanism despite normal coronary anatomy. During followup, she developed ST-elevation myocardial infarction, and a subsequent CAG revealed coronary spasm. She was diagnosed with vasospastic angina (VSA) and treated with nitrates and diltiazem. The patient is now free of epigastric pain and arrhythmic episodes. This case highlights the diagnostic challenges of VSA because of its atypical presentation and the limitations of resource-constrained settings, which can result in delayed diagnosis. Clinicians should consider VSA in patients with angina, sudden cardiac death, and abnormal EST results, especially in the absence of significant stenosis. While CAG with provocative testing is the standard diagnostic approach, alternative diagnostic pathways should be applied in resource-limited settings. Treatment options include medications and ICD placement, which should be considered for patients with high-risk VSA and recurrent ventricular arrhythmias.