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A woman with recurrent chest pain and ST-segment elevation

Published:November 17, 2015DOI:https://doi.org/10.1016/j.ejim.2015.11.008

      Abstract

      A 32-year-old female presents with recurrent episodes of unprovoked chest pain associated with inferior ST-segment elevation and reciprocal ST-segment depression. Coronary angiography during one of these episodes revealed coronary artery spasm that spontaneously resolved followed by resolution of these electrocardiographic changes. There was no atherosclerotic occlusive disease. Her cardiac markers were normal and echocardiogram showed no regional wall motion abnormalities. Electrocariogram and angiography findings are shown in Fig. 1.

      1. Introduction

      A 32-year-old African American woman with a history of hypertension, diabetes mellitus and chronic smoking presented with chest pain. Her electrocardiogram (ECG) showed an ST-segment elevation (STE) in the inferior leads with reciprocal ST-segment depression (STD) alarming for an acute inferior STEMI (Fig. 1a ). She has been having similar episodes of chest pain over the previous 2 years lasting for few minutes and occasionally relieved with nitroglycerin and had a coronary angiogram 15 months earlier showing no occlusive disease. We performed a coronary angiography which showed disease in the proximal and distal RCA (Fig. 1b) that spontaneously resolved followed by TIMI III flow (Fig. 1c) and resolution of STE (Fig. 1d). The cardiac markers were normal and echocardiography showed normal left ventricular function and no wall motion abnormalities. She was discharged on calcium channel blocker, long acting nitrate and statin and was advised to stop smoking. Nonetheless, she continued to have frequent clusters of nonexertional chest pain without clear provocation factors. When ECG is performed during these episodes, it would reveal STE in the RCA territory.
      Figure thumbnail gr1
      Fig. 1Panel A: Electrocardiogram showing ST-segment elevation in leads II, III, aVF with reciprocal ST-segment depression. Panel B: coronary angiography showing coronary artery spasm in the proximal and distal right coronary artery that resolved spontaneously followed by TIMI III flow (panel C) and resolution of ST-segment elevation (panel D).
      What is the diagnosis?

      2. Diagnosis

      The current presentation with chest pain, transient STE with reciprocal ST-segment depression and focal coronary artery spasm without angiographic evidence of atherosclerotic coronary disease is explained by vasospastic angina (other names include variant or Prinzmetal angina). Coronary artery spasm is an important cause of chest pain which if prolonged may lead to complications such as myocardial infarction, transient high grade AV block, ventricular tachycardia, and sudden death. Unlike patients with angina due to occlusive coronary disease, these patients characteristically have normal exercise tolerance, and their chest pain usually occur in early morning hours unrelated to increased cardiac workload and tends to be cyclic in nature, occurring in 3–6 month clusters of recurrent attacks, separated by relatively asymptomatic periods, with a gradual reduction of symptoms long-term [
      • Yasue H.
      • Nakagawa H.
      • Itoh T.
      • Harada E.
      • Mizuno Y.
      Coronary artery spasm—clinical features, diagnosis, pathogenesis, and treatment.
      ]. Although patients with vasospastic angina may experience significant morbidity, their long-term mortality is low especially in those who can tolerate calcium channel antagonists and avoid smoking [
      • Bory M.
      • Pierron F.
      • Panagides D.
      • Bonnet J.L.
      • Yvorra S.
      • Desfossez L.
      Coronary artery spasm in patients with normal or near normal coronary arteries. Long-term follow-up of 277 patients.
      ]. Predictors of poor prognosis include ongoing smoking, concurrent coronary atherosclerosis, intolerance to calcium channel blockers, and spasm of multiple coronary arteries [
      • Yasue H.
      • Takizawa A.
      • Nagao M.
      • Nishida S.
      • Horie M.
      • Kubota J.
      • et al.
      Long-term prognosis for patients with variant angina and influential factors.
      ]. In the presented case, spasm was always in a single artery: the RCA and this was evident during her presentations as STE in lead III > lead II and STD in aVL > lead I suggesting that the RCA is likely the culprit vessel.

      Conflict of interest statement

      The authors state that they have no conflicts of interest.

      Acknowledgments

      We have received no funding for this report. All authors have read and approved the final submitted manuscript.

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