Severe coronary vasospasm in the catheterization laboratory

Abstract

In 2005, a 50-year-old woman with a history of migraines, hypertension and type 2 diabetes underwent three-vessel coronary artery bypass graft surgery for symptomatic ischemic heart disease. In 2006, she had two percutaneous coronary interventions for severe stenotic lesions immediately distal to the site of the graft anastomosis in both her left anterior descending artery and her ramus branch (Figure 1A). Four months later, she was admitted to the hospital for recurrent chest pain. Her cardiac enzymes were normal. Her electrocardiogram was unchanged from a previous one, which showed anterolateral ST and T wave abnormalities consistent with myocardial ischemia. Selective coronary angiography showed diffuse, severe coronary artery vasospasm involving both her native vessels (Figure 1A) as well as the right and left internal mammary artery bypass grafts (Figure 1B). Following 200 μg of intracoronary nitroglycerin administration, the vasospasm resolved and revealed patent native and graft anatomy (Figure 1B). She was subsequently treated for variant (Prinzmetal’s) angina with a combination of oral nifedipine, diltiazem and nitrates. Figure 1) A Left coronary angiogram before intracoronary nitroglycerin, showing diffuse, severe native coronary artery vasospasm with a coronary stent visualized in the intermediate branch (arrowhead). Note the absence of graft anatomy. B Left coronary angiogram ... Variant angina is an infrequent cause of myocardial ischemia, but should always be considered in the differential diagnosis of chest pain in the context of younger patients and a history of vasospastic disorders. In the present case, coronary revascularization could have been avoided if this diagnosis was considered at the time of the initial cardiac investigations.