증례 Fig. 1. Computed tomography scan with contrast enhancement demonstrated intramural hematoma extending from aortic arch to thoracic descending aorta

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1 Case Reports Korean Circulation J 2000;3011: 대동맥벽내혈종환자에서베타차단제사용후 이형협심증에인한심근경색증 1 예 김중선 김병극 고영국 한승혁 서혜선 최동훈 조승연 A Case of Myocardial Infarction Caused by a Variant Angina during Treatment with -blocker of Intramural Hematoma Jung Sun Kim, MD, Byeong Keuk Kim, MD, Young Kuk Ko, MD, Seung Hyeok Han, MD Hye Sun Soe, MD, Donghoon Choi, MD and Seung Yeon Cho, MD 1 Cardiology Division, Yonsei Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea ABSTRACT Variant angina is characterized by repeated attack at rest associated with ST-segment elevation on ECG and caused by the spasm of coronary artery. But, the pathogenesis of spasm is not well known. A 44-year old man was transferred for the management of intramural hematoma at descending thoracic aorta and uncontrolled hypertension. We Sstarted to control hypertension with nitroprusside, propranolol, amlodipine, and doxazocin. At 4th hospital day, severe chest pain, dizziness, and diaphoresis were developed, and ECG showed not only STsegment elevation on lead II, III, avf but also 2AV block Mobitz type II. CK-MB revealed 52.3 ng/dl. When coronary angiography performed emergently, it showed total occlusion of right coronary artery RCA and diffuse minimal narrowing of left anterior descending coronary artery LAD. After nitroglycerin was infused via right coronary catheter, the RCA was opened completely, and reperfusion arrhythmia was developed. Medication were changed to nifedipine, diltiazem, nicorandil, isosorbide mononitrate and he had no more chest pain. Korean Circulation J 2000;3011: KEY WORDSVariant angina Intramural hematoma -blocker. 서 론 1455

2 증례 Fig. 1. Computed tomography scan with contrast enhancement demonstrated intramural hematoma extending from aortic arch to thoracic descending aorta Korean Circulation J 2000;3011:

혈종이 두께 1.2 cm, 총 길이는 23 cm, 최장 대동맥 직 상 Ⅱ, Ⅲ, avf에 ST분절의 상승 소견있어 nitroglycerin 경 4 cm으로 발견되어(Fig.

Electrocardigraphy showed initial (A), marked ST segment at II, III, avf after chest pain developed (B) and Isoelectrical sinus rhythm after chest pain

3 혈종이 두께 1.2 cm, 총 길이는 23 cm, 최장 대동맥 직 상 Ⅱ, Ⅲ, avf에 ST분절의 상승 소견있어 nitroglycerin 경 4 cm으로 발견되어(Fig. 1) nitroprusside 정맥내 주 투여 후 호전되었다가 다시 수축기 혈압 90 mmhg까지 입, propranolol 240 mg, amlodipine 10mg, doxazo- 떨어지는 소견과 심전도상 Ⅱ, Ⅲ, avf에 ST분절의 상 cin 4 mg으로 치료를 시작하였다. 승 소견과 2도 방실 결절 차단(Morbitz type II)이 나 내원 4일째 발한을 동반한 흉통을 호소하면서 심전도 A B Fig. 2. Electrocardigraphy showed initial (A), marked ST segment at II, III, avf after chest pain developed (B) and Isoelectrical sinus rhythm after chest pain subsided (C). C A B Before NTG infusion C 타나면서 심근 효소 검사상 CK-MB ng/dl의 상 After NTG infusion Before NTG infusion After NTG infusion Fig. 3. Coronary angiography. A Left coronary angiogram revealed the resolution of diffuse luminal narrowing after nitroglycerin. B Right coronary angiogram revealed the resolution of total occlusion after nitroglycerin via intracoronary artery. C Reperfusion arrythmia developed iust after the resolution of coronary spasm. 1457

4 고찰 1458 Korean Circulation J 2000;3011:

5 REFERENCES 1) Kazerooni EA, Bree RL, Williams DM. Penetrating atherosclerotic ulcers of the descending thoracic aorta evaluation with CT and distinction from aortic dissection. Radiology ) Nienaber CA, von Kodolitsch Y, Petersen B, Loose R, Helmchen U, Haverich A, et al. Intramural hemorrhage of the thoracic aorta diagnostic and therapeutic implication. Ciculation ) Prinzmetal M, Kennamer R, Merliss R, Wada T, Bor N. Angina pectoris a variant form of angina pectoris. Am J Med ) Coronary spasm by a coronary stent. Korean Circulation J ) Maseri A, Kaski JC. Pathogenetic mechanisms of coronary artery spasm. JACC ) Mayer S, Hillis LD. Prinzmetal s variant angina. Clin. Cardiol ) Robertson RM, Wood AJJ, Vaughn WK, Robertson D. Excerbation of vasotonic angina pectoris by propranolol. Circulation ) Julian DG. Is the use of beta blockade contraindicated in the patient with coronary spasm? Circulation supp II-92. 9) Chang JN, Chi DH, Park GS, Lee KH, Cho SW, Koh KK, et al. Variant angina diagnosed by beta-blocker provocation test and a case of subendocardial infarction induced by this test. Korean Circulation J ) Mikio O, Koichi T, Yoshimasa M, Tsunehiro K, Yoshihito S, Chikao G. Extremely rapid regression of aortic intramural hematoma. J Thorac Cardiovasc Surg ) Hillis LD, Braunwald E. Coronary artery spam. N Engl J Med ) Lange RA, Cigarroa RG, Yancy CW, Willard JE, Popma JJ, Sills MN, et al. Cocaine-induced coronaryartery vasoconstriction. N Engl J Med ) Nobuyoshi M, Abe M, Nosaka H, Kimura T, Yokoi H, Hamasaki N, et al. Statistical analysis of clinical risk factors for coronary artery spasm indentification of the most important determinant. Am Heart J ) Adams, JN, Denver MA, Rae AP. Coronary artery spasm leading to life threatening arrhythmias Heart ) Nakamura M, Takeshita A, Nose Y. Clinical characteristics associated with myocardial infarction, arrhythmias, and sudden death in patients with vasospastic angina. Circulaton ) Bory M, Pierron F, Panagides D, Bonnet JL, Yvorra S, Desfossez L. Coronary artery spasm in patients with normal or near normal coronary arteries. Eur Heart J ) Walling A, Waters DD, Miller DD, Roy D, Pelletier GB, Theroux P. Long term prognosis of patients with variant angina. Circulation ) Freedman SB, Richmond DR, Alwyn M, Kelly DT. Late follow-up 41 to 102 month of medically treated patients with coronary artery spasm and minor atherosclerotic coronary obstruction. Am J Cardiol ) Scholl JM, Veau P, Benacerraf A, Brau J, Hennetier G, Achard F. Long-term prognosis of medically treated patients with vasospastic angina and no fixed significant coronary atherosclerosis. Am Heart J

of medication with calcium channel blocker or nitrate compared with those in previous studies. Korean Circulation J 1999;293: KEY WORDSVariant

of medication with calcium channel blocker or nitrate compared with those in previous studies. Korean Circulation J 1999;293: KEY WORDSVariant Original Articles Korean Circulation J 1999;293:276-284 급성심근경색증으로발현한변이형협심증환자의 임상적, 관동맥조영검사상특성및장기추적관찰 두영철 김재삼 채경수 송관욱 홍경순 박대균 한규록오동진 유규형 임종윤 고영박 이광학 이영 Clinical and Angiographic Characteristics and Long-term