Refractory vasospastic angina in a patient with autoimmune hepatitis managed by using combined non-invasive provocation tests: A case report

Abstract

Corticosteroids have emerged as a feasible treatment option for patients with refractory vasospastic angina (VSA) who have an allergic disease or hypereosinophilia. However, reports on VSA following the administration of corticosteroids are scarce. Herein, we present the rare case of a 49-year-old Japanese man who developed VSA while receiving corticosteroids for treatment of autoimmune hepatitis. Invasive coronary angiography and pharmacological spasm provocation tests under oral prednisolone (20 mg) revealed multi-vessel spasms with ST elevation but no obstructed coronary arteries. To assess the effectiveness of the pharmacotherapy following a Ca2+ antagonist (benidipine) administration, we adopted non-invasive and non-pharmacological coronary vasospasm provocation tests (cold-pressor stress, isometric handgrip exercise, and hyperventilation). These tests revealed transient ST elevations with angina, which prompted us to add other vasodilators to control the high disease activity. These tests can be particularly valuable in cases where spasmogenicity fluctuates with changes in corticosteroid dosage during prolonged treatment of hepatitis. Learning objectiveCorticosteroids can induce vasospastic angina (VSA) and corticosteroid-induced VSA may relapse in a dose-dependent manner. Discontinuation of corticosteroids is often difficult, and long-term administration may be inevitable. Evaluation of the fluctuated spasmogenicity during long-term observation of autoimmune hepatitis may be crucial.>