Refractory Chest Pain Research Articles

Spinal cord stimulation in a patient with an implantable cardioverter defibrillator for managing chronic chest pain: a case report and literature review.

The simultaneous use of spinal cord stimulation (SCS) and an implantable cardioverter-defibrillator (ICD) is safe and effective in selected patients with refractory chest pain. Our case highlights successful pain management with SCS without compromising ICD function. Careful patient selection, low device settings, and ongoing monitoring are crucial for achieving optimal outcomes.

Cardiac PET and CMR in Diagnosis of Epi-pericardial Fat Necrosis Associated with Severe Refractory Chest Pain Following Arrhythmia Ablation

Cardiac PET and CMR in Diagnosis of Epi-pericardial Fat Necrosis Associated with Severe Refractory Chest Pain Following Arrhythmia Ablation

Interrupted aortic arch with bicuspid aortic valve stenosis in an adult: A case report.

The case report describes a rare instance of an interrupted aortic arch (IAA) with bicuspid aortic valve stenosis in a 48-year-old male patient with a one-year history of refractory hypertension, chest pain, and numbness in the upper and lower extremities. A single-stage operation was performed through a midline sternotomy, involving aortic valve replacement and posterior pericardial ascending-to-descending aortic bypass. Managing such rare conditions can be challenging due to limited guidelines, no meaningful conclusion may be made as to whether single-stage or two-stage repair is superior. Final management decision in adult patients with IAA must be individualized and depend on the associated malformations, patient preference, and precise anatomy imaging. The single-stage posterior pericardial ascending-to-descending aortic bypass appears as a safe surgical method in such cases when concomitant cardiac procedures are indicated.

Refractory Coronary Vasospasm After Spine Surgery; A Rare Case Report

Refractory vasospastic angina (RVSA) is a rare condition leading to several episodes of constriction of coronary arteries which eventually leads to myocardial ischemia. Calcium-channel blockers (CCBs) and nitrates are usually used, however, sometimes the vasospasm is refractory and recurrent leading to high morbidity and mortality. A 35-year-old man known case of hypertension underwent two times operation due to T9-T10 discopathy and decompressive laminectomy of three segments T8/T9/ T10 following a previous car accident 4 months before this admission. Three days postoperatively he developed chest pain, dyspnea and diaphoresis. Electrocardiography showed inverted T wave in leads I, II and ST elevation in pericardial leads of V1-V4. Left anterior descending (LAD) artery stenosis was present (99%) at mid part that resolved after Trinitroglycerin (TNG) injection during angiography. Totally, he underwent 3 times coronary angiography due to recurrent chest pain refractory to conventional management of Prinzmetal’s angina. Coronary stent could not be placed due to severe spasm. Finally, he developed refractory chest pain and dyspnea and cardiac arrest in the CCU despite receiving intravenous high dose TNG, Diltiazem, Nicorandil and Hydrocortisone. He expired after several times of cardiopulmonary resuscitation. Refractory VSA after spine surgery has not been reported in the literature yet. This patient was resistant to available medications. There is no consensus regarding the treatment unfortunately. Randomized clinical trials have to be done to find ways regarding unconventional treatment options such as alpha-2-agonists, Corticosteroids, rho-kinase-inhibitors, statins and magnesium. Despite the fact, some surgical interventions with sympathetic denervation like left-stellate-ganglion denervation must be assessed.

Use of intravenous lidocaine in a patient with refractory chest pain secondary to Takayasu arteritis. Case report

Use of intravenous lidocaine in a patient with refractory chest pain secondary to Takayasu arteritis. Case report

673 A CRACK AND A CLOT

Abstract A 74-year-old man with a history of ischaemic heart disease (multiple percutaneous coronary interventions (PCI)), broke his ankle. Therefore, he discontinued dual antiplatelet therapy (DAPT) -acetylsalicylic acid plus clopidogrel- and started enoxaparin sodium 4000 UI/day on medical advice. A few days later, he was admitted to the emergency department for refractory chest pain, vomit and syncope. Twelve-lead electrocardiogram (ECG) showed a sinus rhythm interrupted by frequent premature ventricular contractions in a pattern of trigeminy. The transthoracic echocardiogram revealed a mildly dilated LV with normal wall thickness and marked hypokinesis/ akinesis in apical, infero-lateral and antero-lateral walls, with a 33% ejection fraction. High sensitivity cardiac troponin was increased, and a second ECG showed a diffuse ST segment depression. The patient was loaded with aspirin and emergently taken to the cardiac catheterization lab. Coronary angiography showed a very late stent thrombosis of the left circumflex artery (LCx), with occlusion of the extreme distality of the second obtuse marginal artery and a 50-60% intrastent restenosis of the ostium-proximal tract of the left anterior descending artery (LAD). Given the non-obstructive nature of the thrombus, risk of peripheral embolization, TIMI flow grade 3 and improvement of symptoms, the decision was made to adopt a conservative strategy with loading dose of ticagrelor, heparin and tirofiban infusion. Besides, an optical coherence tomography (OCT) control was scheduled for the next day. OCT of the LCx revealed a well apposed and well expanded stent with a non-obstructive residual thrombus, nevertheless not visible on angiography. Thus, the tirofiban infusion was prolonged up to 48 hours. OCT of the LAD detected a fibro-calcific disease determining a significant restenosis of the distal left main (LM)-LAD ostium. OCT-guided provisional stenting with two drug eluting stents on LM-LAD-LCx was performed successfully. The patient was discharged home on acetylsalicylic acid (lifelong), ticagrelor (for 12 months) and enoxaparin sodium 4000 UI/day (according to specialist indication). DAPT is superior to anticoagulant therapy in preventing stent thrombosis in patients undergoing PCI, and a more informed inter-specialist communication is needed. Intracoronary imaging can help in the management of stent failure and in the guidance of complex PCI, allowing a patient-tailored treatment.

Refractory pleuritic chest pain: A troublesome consequence of pulmonary embolism.

A sixteen-year-old girl presented to the Emergency Department (ED) with the chief complaint of chest pain This article is protected by copyright. All rights reserved.

S461 Short Term Outcomes of Per Oral Endoscopic Myotomy for Patients With Refractory Atypical Chest Pain: A New Indication for POEM?

S461 Short Term Outcomes of Per Oral Endoscopic Myotomy for Patients With Refractory Atypical Chest Pain: A New Indication for POEM?

Risks of refractory chest pain after peroral endoscopic myotomy in achalasia-related esophageal motility disorders: short-term results from a multicenter study in Japan

The etiology of chest pain in achalasia-related esophageal motility disorders and the frequency and risk factors of persistent chest pain after peroral endoscopic myotomy (POEM) remain unclear. A multicenter cohort study including 14 hospitals was conducted to elucidate the characteristics of patients with chest pain and the efficacy of POEM. Consecutive cases of achalasia-related esophageal motility disorders included 2294 (64.2%) and 1280 (35.8%) patients with and without chest pain, respectively. Among the 2107 patients with chest pain who underwent POEM, we observed complete remission in 1464 patients (69.5%) and nonremission in 643 patients (30.5%), including a partial response in 619 patients (29.4%) and resistance in 24 patients (1.1%). Multivariate analysis revealed that advanced age (odds ratio [OR], .28), male sex (OR, .70), prior treatment (OR, 1.39), and sigmoid type (OR, .65) were related to the prevalence of chest pain. Long disease duration (OR, .69) and esophageal dilation (OR, .79) were related to decreased severity. POEM improved patients' quality of life that was hindered by chest pain. Early onset (OR, 1.45), advanced age (OR, .58), male sex (OR, .79), prior treatment (OR, 1.37), and posterior myotomy (OR, 1.42) were associated with nonremission after POEM; high-resolution manometry (HRM) findings and myotomy length showed no statistical significance on pain etiology and persistence after POEM. The prevalence and severity of chest pain were dependent on age, sex, disease duration, prior treatment, and esophageal morphology rather than HRM findings. The efficacy of POEM is satisfactory; however, residual pain was often observed. Excessively long myotomy can be avoided, and anterior myotomy may be recommended.

Geriatric patients with esophageal motility disorders benefit more from minimally invasive peroral endoscopic myotomy: a multicenter study in Japan.

Geriatric patients with existing studies on the safety and efficacy of peroral endoscopic myotomy (POEM) for achalasia involve small sample sizes and single institutions. However, multi-center, large-scale data analyses are lacking. The study aimed to clarify the characteristics of geriatric patients with esophageal motility disorders (EMDs) and determine the procedure-related outcomes and clinical course following POEM. This cohort study included 2,735 patients with EMDs who were treated at seven Japanese facilities between 2010 and 2019. The patients' characteristics and post-POEM clinical courses were compared between the geriatric (age ≥ 75years; n = 321) and non-geriatric (age < 75years; n = 2,414) groups. Compared with the non-geriatric group, the geriatric group had higher American Society of Anesthesiologists physical status scores; more recurrent cases; lower incidence of chest pain; and higher incidence of type III achalasia, distal esophageal spasm, and Jackhammer esophagus. Furthermore, the incidence of sigmoid esophagus was higher, although esophageal dilation was not severe in this group. POEM was safe and effective for geriatric patients with treatment-naïve and recurrent EMDs. Furthermore, compared with the non-geriatric group, the geriatric group had lower post-POEM Eckardt scores, fewer complaints of refractory chest pain, and a lower incidence rate of post-POEM reflux esophagitis. Geriatric patients are characterized by worse clinical conditions, more spastic disorders, and greater disease progression of EMDs, which are also the indications for minimally invasive POEM. POEM is more beneficial in geriatric patients as it has lowering symptom scores and incidence rates of reflux esophagitis.

Analysis of the factors related to the early outcomes of Type B Acute Aortic Syndromes

Objective: To determine the outcomes of endovascular treatment (ET) of Type B Acute Aortic Syndrome (AAS) and factors related to mortality and Spinal Cord ischemia. Methods: This was a retrospective cohort of complicated AAS patients who underwent endovascular treatment. The primary outcome variable was mortality rate and clinical outcomes. The secondary outcome variable was SCI. Results: Overall, 32 patients were evaluated, 10 patients submitted to CM and 22 patients ET. 100% of the patients had arterial hypertension, with a higher prevalence of male gender (53.1%). There was a higher prevalence of acute aortic dissection Stanford B with 19 cases (59.4%). Among the 22 patients submitted to interventional therapy, most of them thoracic endoprosthesis (TEVAR), with 16 patients (72.7%). A logistic regression showed that refractory chest pain (HR = 9,57; p = 0.005), aortic diameter higher than 40mm (HR = 16.65; p &lt; 0.001), chronic renal failure (CRF) (HR = 5.2; p = 0.009) and SCI (HR = 1.89; p = 0.029) were related to increased mortality rate. Otherwise, male gender (MG) (HR = 17.20; p &lt; 0.001), concomitant TEVAR + EVAR (HR = 3.88; p = 0.048), malperfusion (HR = 3.88; p = 0.038) and number of internal iliac patency (IIP) (HR = 6.52; p = 0.016) were associated to SCI. Conclusion: This study concluded that refractory chest pain, aortic diameter higher than 40mm, CRF and SCI were related to increased mortality rate. MG, concomitant TEVAR + EVAR, malperfusion and number of IIP were associated to SCI.

One-year prospective follow-up of women with refractory chest pain and no obstructive coronary artery disease at a women's heart centre

One-year prospective follow-up of women with refractory chest pain and no obstructive coronary artery disease at a women's heart centre

Endovascular Repair of a Complicated Acute Type B Aortic Dissection Using a Combination of the STABILISE and CERAB Techniques

Introduction: Endovascular treatment of type B aortic dissection has focused on covering the proximal entry tear. However, recently, concern has emerged regarding the distal aortic remodeling and new techniques such as the Stent-Assisted Balloon-Induced Intimal Disruption and Relamination (STABILISE) technique have gained acceptance. We describe a case report in which the STABILISE technique was used in addition with the Covered Reconstruction of the Aortic Bifurcation (CERAB) technique for complete aortic remodeling. Methods: Clinical data were collected from the hospital's records. Results: A 34-year-old male, with a history of hypertension was admitted at the emergency department for acute-onset back pain, severe hypertension and right lower limb ischemia. A CT-Angiography confirmed a type B aortic dissection with true lumen compression and right common iliac artery occlusion. At first, blood pressure and pain were controlled with IV drugs, however the lower limb ischemia persisted. A plan was made to first treat the limb ischemia and delay the aortic repair for the sub-acute phase, if necessary. A common iliac artery kissing stent was performed using Atrium Advanta V12® (10mm) stents and a self-expandable uncovered stent to the external iliac on the right side. The patient recovered well, however, 5 days later, refractory chest pain and hypertension developed. A CT-Angiography showed severe true lumen compression at the visceral aorta and we decided to perform an urgent repair of the aortic dissection. After true lumen catheterization, a TEVAR was performed landing over the left subclavian artery (COOK®ZTA P-32-201) followed by deployment of a bare-metal dissection stent ending 2 cm below the renal arteries (COOK®ZDES 36-180). A control angiography showed false lumen exclusion at the proximal aorta, however the distal aortic true lumen was still severely compressed. For that reason, a STABILISE was performed using a non-compliant 28mm balloon proximally and a 23mm balloon distally. Because the true lumen was still compressed at the infra-renal aorta, we decided to proceed with a CERAB technique, using a Bentley® Aortic BeGraft (18x48mm) deployed just distal to the renal arteries. Proximal flaring of the stent was performed using the 23mm non-compliant balloon. Two 10x59mm Atrium Advanta® V12 stents were used for the iliac extensions ending inside the previous iliac kissing stents. Angiographic control was optimal, and the patient recovered well. However, the patient was still dependent on 4 oral anti-hypertensive drugs, so a new CT-Angiography was performed and showed an intimal flap inside the right renal artery. Under local anesthesia, a Cordis® Palmaz Blue (6x18mm) stent was deployed in the right renal artery through the aortic dissection stent. The patient was latter discharged with adequate hypertension control under two oral anti-hypertensive drugs and the control CT one month after treatment showed complete remodeling of the aorta and perfusion of all visceral branches. Conclusion: We report a case of a combination of the STABILISE and CERAB techniques used to treat an acute type B aortic dissection. This combination allowed for a covering of both the entry tear and the distal re-entry tears resulting in a complete flap apposition, false lumen obliteration and optimal remodeling. Disclosure: Nothing to disclose

There might be a distinctive clinical phenotype of constipation with non-cardiac chest pain which responds to combination laxatives: A retrospective, longitudinal symptom analysis.

Proton pump inhibitor (PPI)-refractory non-cardiac chest pain (NCCP) is often resolved when constipation was relieved. This study aimed to investigate the clinical features of patients with both NCCP and constipated functional bowel disorders (FBD).Among 692 consecutive patients diagnosed with functional constipation or irritable bowel syndrome with constipation and underwent anorectal manometry (ARM) in our hospital, PPI-refractory NCCP was present in 37. The clinical course of various torso symptoms including NCCP and ARM findings were retrospectively evaluated.The mean age was lower in the NCCP than in the non-NCCP group (57.4 vs 61.3 years, respectively, P = .042). Back pain (16.2% vs 2.0%, P < .001) and sharp abdominal pain (13.5% vs 0.9%, P < .001) were more common in the NCCP group. Increased resting pressure (16.2% vs 6.9%, P = .036) and squeezing pressure (62.2% vs 50.7%, P = .049) of the anal sphincter, increased urgency volume (40.5% vs 23.2%, P = .004), and maximal volume (25.7% vs 15.0%, P = .032) for rectal sensation were more frequently observed in the NCCP group. After taking laxatives for 1 to 3 months, 81.1% of patients with NCCP reported improvement.Subjects with NCCP showed decreased rectal sensation more frequently at anorectal manometry. Majority of patients with NCCP reported improvement of symptom upon relief of constipation. Constipation might be a therapeutic target in patients with NCCP related to constipated functional bowel disorders.

Evaluation of Safety and Efficacy of Radiofrequency Lesioning of Thoracic Dorsal Root Ganglion in Chest Cancer Pain Patients

Background: since cancer-associated pain is a common occurrence in malignancies involving the chest. In these cases, pain is complex and may have visceral, somatic or neuropathic components. It has been noticed that the number of cancer patients with refractory chest pain is increasing with more cancer prevalence, also with the advances in therapy and prolonged life expectancy. The demand for interventional procedures to control pain for these patients also increases. Interventional pain procedures are indicated for refractory pain when analgesic drugs are ineffective or associated with intolerable side effects. In controlling cancer pain it is commonly inadequately managed for these patients leading to suffer form of physical disabilities, psychological disturbance and avoiding treatment. Aim of the work: this study was designed to test both the efficacy and safety of thermo-coagulative ablation of the thoracic dorsal root ganglia for pain control in cancer patients that have refractory chest pain. Methodology: this prospective randomized study was conducted in the National Cancer Institute, Cairo University and Aswan University after board approval from October 2016 to March 2018. Sixty-five patients with Refractory Chronic Chest Cancer Pain were selected randomly and prospectively from the pain clinic of both the National Cancer Institute of Cairo University and Aswan University, after taken an informed written consent from the patient. The complete duration of the follow up lasted 3 months post-interventional with assessments after 1 week, 1 month and 3 months. At each follow up each patient was re-assessed with the following assessments; VAS, ECOG Performance Status. Results: we found that with effective pain relief there was a significant reduction in the mean VAS values; which means that there was functional improvement, in all the postinterventional follow ups. Also, there was an improvement in the functional state of the patients throughout the follow-up post-intervention with regards to the ECOG performance status from the results.Conclusion: we concluded that thermal radiofrequency ablation is considered an alternative for treating refractory chronic chest cancer pain of several types and causes. This is because of its efficacy, safety and ease of use. It also requires a minimal hospital stay or can even be performed on an outpatient basis.

Evaluation of Safety and Efficacy of Radiofrequency Lesioning of Thoracic Dorsal Root Ganglion in Chest Cancer Pain Patients

Background: since cancer-associated pain is a common occurrence in malignancies involving the chest. In these cases, pain is complex and may have visceral, somatic or neuropathic components. It has been noticed that the number of cancer patients with refractory chest pain is increasing with more cancer prevalence, also with the advances in therapy and prolonged life expectancy. The demand for interventional procedures to control pain for these patients also increases. Interventional pain procedures are indicated for refractory pain when analgesic drugs are ineffective or associated with intolerable side effects. In controlling cancer pain it is commonly inadequately managed for these patients leading to suffer form of physical disabilities, psychological disturbance and avoiding treatment. Aim of the work: this study was designed to test both the efficacy and safety of thermo-coagulative ablation of the thoracic dorsal root ganglia for pain control in cancer patients that have refractory chest pain. Methodology: this prospective randomized study was conducted in the National Cancer Institute, Cairo University and Aswan University after board approval from October 2016 to March 2018. Sixty-five patients with Refractory Chronic Chest Cancer Pain were selected randomly and prospectively from the pain clinic of both the National Cancer Institute of Cairo University and Aswan University, after taken an informed written consent from the patient. The complete duration of the follow up lasted 3 months post-interventional with assessments after 1 week, 1 month and 3 months. At each follow up each patient was re-assessed with the following assessments; VAS, ECOG Performance Status. Results: we found that with effective pain relief there was a significant reduction in the mean VAS values; which means that there was functional improvement, in all the postinterventional follow ups. Also, there was an improvement in the functional state of the patients throughout the follow-up post-intervention with regards to the ECOG performance status from the results.Conclusion: we concluded that thermal radiofrequency ablation is considered an alternative for treating refractory chronic chest cancer pain of several types and causes. This is because of its efficacy, safety and ease of use. It also requires a minimal hospital stay or can even be performed on an outpatient basis.

Evaluation of Safety and Efficacy of Radiofrequency Lesioning of Thoracic Dorsal Root Ganglion in Chest Cancer Pain Patients Daily Activities and their Quality of Life

Background: in controlling cancer pain it is commonly inadequately managed for these patients leading to suffer in the form of physical disabilities, psychological disturbance, avoiding treatment. Therefore pain that is caused by cancer may directly affect the patient's quality of life; by having an effect on his/her daily activity, physical state and also psychological and emotional status. Thus, making pain relief and control the patient's right; right for a new life "pain free" or at least tolerable non-disabling pain. Aim of the work: this study aimed to test both the efficacy and safety of thermo-coagulative ablation of the thoracic dorsal root ganglia for pain control in cancer patients that have refractory chest pain And the impact on quality of life for patients. Patients and Methods: our prospective study was done on sixty-five patients selected from pain clinics of both the National Institute of Cancer, Cairo University and Aswan University with refractory chronic chest cancer pain according to the inclusion and exclusion criteria. The complete duration of the follow up lasted 3 months postinterventional; with assessments after 1 week, 1 month and 3 months. At each follow up each patient was reassessed with the following assessments; VAS, ECOG performance status, QOLS, drug consumption, side-effects (complications) and patient satisfaction. Results: we found that with effective pain relief there was a significant reduction in the mean VAS values which means that there was functional improvement, in all the postinterventional follow ups. Also, there was an improvement in the functional state of the patients throughout the follow-up post-intervention with regardsto the ECOG performance statusfrom the results. In addition to the ECOG improvement there was also a significant improvement in the QOL (Quality of Life) results, which was due to the pain relief. Regarding drug consumption, it was recorded that all three drugs; pregabalin, oxycodone and amitryptline, should maximum reduction after 1 month following the intervention, with a slight increase 3 months post-interventional, which matched the degree of pain reduction based on the pain scaling scores. Only 11% of our patients were found with numbness and neuritis, which were the only two complications reported. With regards to our patients, 30.6% certainly would repeat the procedure, 54.8% probably would, and 12.9 % probably would not while, only 1.6% certainly would not repeat it. With25.8% certainly would recommend the same procedure, 56.5% probably would, 14.5% probably would not and only 3.2% certainly would not recommend it. Conclusion: we concluded that thermal radiofrequency ablation is considered an alternative for treating refractory chronic chest cancer pain of several types and causes. This is because of its efficacy, safety and ease of use, patient’s quality of life of was largely affected.

Does a Women's Heart Centre Change Clinical Outcomes in Women with Refractory and Undiagnosed Chest Pain Syndromes?

Does a Women's Heart Centre Change Clinical Outcomes in Women with Refractory and Undiagnosed Chest Pain Syndromes?

Acute coronary syndrome secondary to allergic coronary vasospasm (Kounis Syndrome): a case series, follow-up and literature review

BackgroundKounis syndrome (KS) is the concurrence of acute coronary syndrome associated with mast-cell and platelet activation in the setting of hypersensitivity and allergic or anaphylactic insults. Many drugs and environmental exposures had been reported as inducers, but various inducers and the mechanism of KS remained unknown till now. The widely used traditional Chinese medicine (TCM) as a potential sensitizer were scarcely reported to induce allergic vasospasm due to the ignorance of the linkage between traditional medicine allergy and vasospasm.Case presentationWe described 5 rare cases of KS including unreported triggers of TCM and abortion, reported the treatment strategy and 1~4 years’ follow-up results, and tried to probe into the etiology of KS. Case 1 and case 2 for the first time reported acute ST-segment elevation myocardial infarction (STEMI) caused by Chinese herbs related allergic coronary vasospasm. Case 3 reported recurrent angina following allergen contact and wheezing, indicating the internal linkage of coronary vasospasm and allergic asthma. Case 4 described a childbearing-age woman suffered refractory ischemic chest pain due to coronary vasospasm in a special period of post-abortion, the attacks suddenly disappeared when her menopause recovered. Case 5 described an isolated episode of allergic coronary vasospasm under exposure of smoking and stress, which was successfully prevented by avoiding the exposures.ConclusionKounis syndrome is not rare but rarely recognized and under-diagnosed. It is necessary to recognize KS and various inducers, especially for the patients suffering refractory vasospastic cardiac attacks concentrating in special periods. Blood test of eosinophil might contribute to diagnose KS and anti-allergic agents might be helpful for controlling KS attacks.

Recurrent coronary spasm necessitating primary percutaneous coronary intervention

Dr Ozan M Demir is ST3 Cardiology in the Department of Cardiology, Watford General Hospital, Hertfordshire WD12 0HG Dr Jonathan Hudson is F1 Cardiology in the Department of Cardiology, Watford General Hospital, Hertfordshire Dr Sarah Ghonim is ST3 Cardiology in the Department of Cardiology, Watford General Hospital, Hertfordshire Dr William Wallis is Consultant Cardiologist in the Department of Cardiology, Watford General Hospital, Hertfordshire Correspondence to: Dr OM Demir (ozanmdemir@gmail.com) occasions with chest pain caused by variant angina relieved by smooth muscle relaxants. However, she ultimately re-presented with ongoing chest pain and ST segment elevation myocardial infarction despite maximal medical therapy. Owing to refractory chest pain and worsening ST segments percutaneous coronary intervention with drug-eluting stents was performed. Subsequently her ST segment elevation resolved. Since stent implantation she has been asymptomatic for 8 months. This case highlights the recurrent course of coronary spasm and demonstrates the role of primary percutaneous intervention for the management of coronary spasm in life-threatening situations. Discussion Variant angina can be managed medically with a combination of calcium-channel blockers, nitrates and nicorandil, all acting to reduce smooth muscle contractility and prevent coronary artery spasm. Drugrefractory variant angina does not respond to treatment with two calcium antagonists plus a long-acting nitrate, and occurs in up to 30% of patients. Variant angina can be a life-threatening condition. Hung et al (2007, 2014) found that 3.2% of patients with coronary artery spasm will present with life-threatening complications, most commonly complete atrioventricular block and ventricular fibrillation. Given its lifethreatening nature, drug-refractory variant