ISSN: 2469-5858

Jiwu et al. J Geriatr Med Gerontol 2018, 4:050

DOI: 10.23937/2469-5858/1510050
Volume 4 | Issue 2
Journal of Open Access

Geriatric Medicine and Gerontology

Case Report

Salbutamol Inhalation Could Induce Fatal Multi-Vessel Coronary

Artery Spasm in COPD Patients
Li Jiwu1, Zhang Ping2* and Shao Liang3*
1
Department of Cardiology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou,
Zhejiang Province, China Check for
updates
2
Department of Neurology, Jiangxi Provincial People’s Hospital, People’s Republic of China
3
Department of Cardiology, Jiangxi Provincial People’s Hospital, People’s Republic of China
*Corresponding author: Shao Liang, Department of Cardiology, Jiangxi Provincial People’s Hospital, No, 92 Aiguo Road,
Donghu District, Nanchang, 330006, Jiangxi, People’s Republic of China, E-mail: shaoliang021224@hotmail.com;
Zhang Ping, Department of Neurology, Jiangxi Provincial People’s Hospital, No, 92 Aiguo Road, Donghu District, Nan-
chang, 330006, Jiangxi, People’s Republic of China, E-mail: zhangkiki520@126.com

Abstract with history of hypertension and COPD (chronic obstruc-

tive pulmonary disease), firstly presented with shorten
Coronary artery spasm is a sudden and intense vasocon-
of breath in Respiratory Department by history and CT
striction of single-or multi-vessel coronary artery. It may be
triggered by several acute stress. This case reports 72-year- image diagnosis as shown in Figure 1. After accepting
old male with salbutamol inhalation suffer fatal multi-vessel salbutamol inhalation therapy, patient had a sudden
coronary artery spasm. After intracoronary administration chest pain, progressive low blood press and shock. There
of nitroglycerin, coronary artery spasm was relieved. It re- was showed a fast sinus rhythm with marked depression
minds us to be cautious of β-agonist administration in respi-
of ST-T segment in V2-V5 chest leads by electrocardio-
ratory patients with coronary artery spasm risk.
gram (ECG) (Figure 2A). Cardiac troponin I, creatine ki-
Keywords nase and lactate dehydrogenase level were significantly
Coronary artery spasm, Salbutamol inhalation, Chronic ob- elevated confirming myocardial injury and death. Pa-
structive pulmonary disease tient was received urgently oral treatment of aspirin 300
mg, clopidrogel 600 mg, and atorvastatin 40 mg before
Introduction CAG (coronary angiography) operation. Emergency CAG
Coronary artery spasm (CAS) is one of the important showed widely spasm of left anterior descending (LAD),
functional cardiac disorders referred to a sudden and left circumflex (CIRC) arteries and right coronary artery
intense vasoconstriction of single-or multi-vessel coro- (RCA) as shown in Figure 3. After intracoronary admin-
nary artery [1,2]. And it is well known to be associated istration of nitroglycerin, coronary artery spasm was re-
to stable angina, acute coronary syndrome, even cardi- lieved. LAD, CIRC and RCA were appeared bigger in cali-
ac sudden death [3-5]. However, coronary angiography bre and were non-obstructive in Figure 3.
also showed that CAS not only occurred at the site of a Discussion
stenosis (either minor or severe) but also in angiograph-
ically normal coronary arteries [5]. Although the causes Inflammation and autonomic nervous system play
and the mechanisms of CAS are still not revealed, in- some roles in coronary artery spasm. Some inflamma-
flammation, oxidative stress and autonomic nervous tory stimulus, such as interleukin-1β, serotonin and his-
system have catch some truth [6-8]. tamine could induce vascular smooth muscle cells hy-
perreactivity which is the key abnormality responsible
Case Report for CAS [9-12]. Also, inflammation is a demonstrated
In our report, a 72-year-old male, a chronic smoker pathophysiological basis of COPD [13]. Interleukin-1β,

Citation: Jiwu L, Ping Z, Liang S (2018) Salbutamol Inhalation Could Induce Fatal Multi-Vessel Coronary
Artery Spasm in COPD Patients. J Geriatr Med Gerontol 4:050. doi.org/10.23937/2469-5858/1510050
Accepted: June 14, 2018: Published: June 16, 2018
Copyright: © 2018 Jiwu L, et al. This is an open-access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction
in any medium, provided the original author and source are credited.

Jiwu et al. J Geriatr Med Gerontol 2018, 4:050 • Page 1 of 4 •

DOI: 10.23937/2469-5858/1510050 ISSN: 2469-5858

Figure 1: Patient presented lung infection and COPD symptom signal by CT screening.

Figure 2: Patient’s ECG change. A) Patient presented chest pain before PCI operation; B) Patient’s chest pain was relieved
after nitroglycerin injection.

Jiwu et al. J Geriatr Med Gerontol 2018, 4:050 • Page 2 of 4 •

DOI: 10.23937/2469-5858/1510050 ISSN: 2469-5858

Figure 3: Coronary angiographies before and after intracoronary administration of nitroglycerin. Widely coronary artery spasm
presented before intracoronary nitroglycerin injection in A1 and B1. After intracoronary nitroglycerin injection, coronary artery
spasm was relieved in A2 and B2.

serotonin and histamine show a high levels in COPD pa- Conflict of Interest
tients [14,15].
The authors state no conflict of interest.
The adverse effects of salbutamol (β-agonist re-
agent) are tachycardia, arrhythmia, and even myocar- Acknowledgement
dial ischemia [16]. But the effect of autonomic nervous The authors disclose receipt of the following finan-
system on CAS is complex. β-blockers may exacerbate cial support for the research, authorship, and/or publi-
angina attacks in patients with variant angina [17]. cation of this article: Supported by the National Natural
Science Foundation of China (Grant No. 81300115) to
Conclusion Liang Shao.
In summary, CAS is at the site of coronary stenosis
or in angiographically normal coronary arteries. It may
References
be triggered by emotional stress, cold exposure, and 1. Maseri A, Beltrame JF, Shimokawa H (2009) Role of coro-
nary vasoconstriction in ischemic heart disease and search
stimulant drugs such as amphetamines and cocaine. But for novel therapeutic targets. Circ J 73: 394-403.
it is rare a case of multi-vessel coronary artery spasm
2. Lanza GA, Careri G, Crea F (2011) Mechanisms of coro-
induced by β-agonist inhalation. As illustrated by our nary artery spasm. Circulation 124: 1774-1782.
case, it must be cautious of β-agonist administration in
3. Ong P, Athanasiadis A, Borgulya G, Voehringer M, Sechtem
respiratory patients with coronary artery spasm risk.
U (2011) 3-year follow-up of patients with coronary artery
Declaration of Conflicting Interests spasm as cause of acute coronary syndrome: The CAS-
PAR (coronary artery spasm in patients with acute coronary
The authors declare no potential conflicts of interest syndrome) study follow-up. J Am Coll Cardiol 57: 147-152.
with respect to the research, authorship, and/or publi- 4. Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, et
cation of this article. al. (2011) ESC guidelines for the management of acute cor-
onary syndromes in patients presenting without persistent

Jiwu et al. J Geriatr Med Gerontol 2018, 4:050 • Page 3 of 4 •

DOI: 10.23937/2469-5858/1510050 ISSN: 2469-5858

ST-segment elevation: The Task Force for the management coronary angiography. Circulation 65: 1299-1306.
of acute coronary syndromes (ACS) in patients presenting
11. Kaski JC, Maseri A, Vejar M, Crea F, Hackett D (1989)
without persistent ST-segment elevation of the European
Spontaneous coronary artery spasm in variant angina is
Society of Cardiology (ESC). Eur Heart J 32: 2999-3054.
caused by a local hyperreactivity to a generalized constric-
5. Romagnoli E, Lanza GA (2007) Acute myocardial infarc- tor stimulus. J Am Coll Cardiol 14: 1456-1463.
tion with normal coronary arteries: Role of coronary artery
12. Fukumoto Y, Shimokawa H, Ito A, Kadokami T, Yonemit-
spasm and arrhythmic complications. Int J Cardiol 117: 3-5.
su Y, et al. (1997) Inflammatory cytokines cause coronary
6. Katayama N, Nakao K, Horiuchi K, Kasanuki H, Honda T arteriosclerosis-like changes and alterations in the smooth
(2005) Disease activities and serum C-reactive protein lev- muscle phenotypes in pigs. J Cardiovasc Pharmacol 29:
els in patients with vasospastic angina pectoris. J Cardiol 222-231.
46: 63-70.
13. Mehta S, Helmersen D, Provencher S, Hirani N, Rubens
7. Park K, Gross M, Lee DH, Holvoet P, Himes JH, et al. FD, et al. (2010) Diagnostic evaluation and management of
(2009) Oxidative stress and insulin resistance: The coro- chronic thromboembolic pulmonary hypertension: A clinical
nary artery risk development in young adults study. Diabe- practice guideline. Can Respir J 17: 301-334.
tes Care 32: 1302-1307.
14. Wang YS, Liu L, Xu XY, Wang JL, Zhou H, et al. (2015) Asso-
8. Yasue H, Horio Y, Nakamura N, Fujii H, Imoto N, et al. ciation of interleukin-1β -511C/T promoter polymorphism with
(1986) Induction of coronary artery spasm by acetylcholine COPD risk: A meta-analysis. Genet Mol Res 14: 4477-4484.
in patients with variant angina: Possible role of the para-
15. Hospers JJ, Postma DS, Rijcken B, Weiss ST, Schouten JP
sympathetic nervous system in the pathogenesis of coro-
(2000) Histamine airway hyper-responsiveness and mortal-
nary artery spasm. Circulation 74: 955-963.
ity from chronic obstructive pulmonary disease: A cohort
9. Kaski JC, Tousoulis D, Gavrielides S, McFadden E, Ga- study. Lancet 356: 1313-1317.
lassi AR, et al. (1991) Comparison of epicardial coronary
16. (2008) “3.1.1.1 Selective beta2 agonists - side effects”. Brit-
artery tone and reactivity in Prinzmetal’s variant angina and
ish National Formulary (57thedn), London: BMJ Publishing
chronic stable angina pectoris. J Am Coll Cardiol 17: 1058-
Group Ltd and Royal Pharmaceutical Society Publishing.
1062.
17. Robertson RM, Wood AJ, Vaughn WK, Robertson D (1982)
10. Bertrand ME, LaBlanche JM, Tilmant PY, Thieuleux FA,
Exacerbation of vasotonic angina pectoris by propranolol.
Delforge MR, et al. (1982) Frequency of provoked coronary
Circulation 65: 281-285.
arterial spasm in 1089 consecutive patients undergoing

Jiwu et al. J Geriatr Med Gerontol 2018, 4:050 • Page 4 of 4 •