Coronary heart disease is the leading cause of death worldwide. Over the past few decades, life expectancy has increased, which has led to an aging population in developed countries, so the average age of patients with acute coronary syndrome (ACS) has steadily increased in recent decades. The inclusion of elderly and senile patients in randomized clinical trials does not reflect the age-related association of these diseases. However, antithrombotic therapy and interventional treatment are the basis of treatment in patients with ACS of any age, including the elderly. For older patients, there may be a mismatch between chronological and biological age. The question of how close the treatment of elderly patients with ACS is to the level of current recommendations and whether it is possible to apply them unconditionally in this group of patients does not have a definite answer. Current recommendations and the underlying randomized clinical trials are focused on any one disease, whereas in the elderly in most cases multimorbid pathology occurs. In general, elderly patients with ACS should be treated using the same methods as younger patients, however, the presence of comorbid diseases in an elderly patient naturally increases the risk of complications, makes the patient’s prognosis heavier, significantly affects treatment tactics, limits the possibility of using conventional approaches when choosing a drug therapy.

The leading cause of myocardial ischemia in case of coronary atherosclerosis and coronary vasospasm combination in one patient is difficult to establish. However, it is important to know for optimal treatment strategy: choosing between beta-blockers and calcium channel blockers as a preferred treatment, need for percutaneous coronary intervention. We present a case of a 56-yearold patient who was admitted with acute coronary syndrome without ST-segment elevation, low Killip class, and low GRACE score. Stress echocardiography revealed inducible transmural myocardial ischemia (regional wall motion abnormalities and ST segment elevation on the  ECG) accompanied by polymorphic ventricular tachycardia. The coronary angiography showed single-vessel moderate stenosis in the left anterior descending artery. There were no changes in comparison with previous angiography. The patient was considered to have vasospastic angina. A probable mechanism is coronary artery spasm at the site of the atherosclerotic plaque. The article is discussed the difficulties in diagnosing vasospastic angina, especially in the presence of borderline stenosis in the coronary artery. We reviewed similar cases and discussed the difficulties of a vasospastic angina diagnosis especially in the presence of moderate coronary artery stenosis, the role of the provocative tests, and the pharmacological management. Demonstrating, discussing and analyzing cases of patients with a combined mechanism of myocardial ischemia is substantiated for further improving their diagnosis and treatment.

39 original articles were analyzed. 8 of them were excluded due to the small sample of patients. The effectiveness of the intravenous Ig, systemic glucocorticosteroids, cyclosporin A, biological agents (etranecept, infliximab, thalidomide) on the basis of the SCORTEN scale and the number of lethal outcomes was evaluated. Information was searched for the following databases: PubMed, ScienceDirect, Wiley Online Library, Google Scholar, Cochrane Library. The systemic glucocorticosteroid (GCs) pulse therapy using only in the phase of disease progression was the most appropriate. Some authors showed a high risk of sepsis development in patients treated with GCs. In patients who received high doses of IVIg (2 g/ kg), mortality was 2.5 times lower compared to the lower one. The number of lethal outcomes in the Cyclosporin A (3 mg/kg/day) group was 3.3 times lower. A high mortality rate was observed in patients receiving thalidomide. The effectiveness of a particular method of therapy, as well as the prognosis of the disease, largely depends on the process severity, the presence and type of concomitant pathology (for example, severe course and negative outcome in patients with cancer). There is no a single point of view regarding the therapy of SSJ and TEN. Thus, a large multicenter randomized studies are crucial.