Diffuse three-vessel coronary artery spasm

Abstract

A 55 year-old male patient visited to an emergency room because of suffering from frequent severe chest pain, mostly occurring in the early morning at rest for 1 month. He never experienced chest pain on exercise. He has smoked. He had a history of hypertension and hyperlipidemia. He performed an exercise test on Bruce protocol and exercised up to 12 min (13.5 METs) without chest pain and significant ST-T segment change on an electrocardiogram.He underwent coronary angiogram through the left radial artery. Baseline coronary angiogram showed spontaneous mild but diffuse three-vessel spasm without significant stenosis ( Fig. 1A-C). He did not complain of chest pain. Following intracoronary infusfion of 20 μg ergonovine maleate for 1 min into the left main coronary artery, he suddenly complained of severe chest pain. Severe diffuse spasm was identified at the left anterior descending and circumflex arteries, and the second diagonal branch was totally occluded (Fig. 1D, arrowhead). Despite severe chest pain and diffuse spasm, any significant changes of the electrocardiogram were not observed (Fig. 2). Following intracoronary injection of nitroglycerin with a total of 800 μg into the left main coronary artery, chest pain was relieved and severe diffuse spasm of the left coronary artery disappeared (Fig. 1E). The diffuse spastic right coronary artery was also dilated than the baseline coronary angiogram after intracoronary injection of 400 μg nitroglycerin into the left main coronary artery (Fig. 1F). He stopped smoking. Now he has been free of chest pain with medications such as isosorbide mononitrate, diltiazem, and atorvastatin. DiscussionThe patients with variant angina show focal or diffuse single or multivessel coronary artery spasm, but diffuse three-vessel coronary artery spasm among patients with variant angina has been rarely reported [1][2][3][4].Ergonovine administration to patients with unrecognized multivessel spasm could be extremely hazardous [5]. To prevent serious lethal complications, we studied to compare clinical and laboratory findings between patients with diffuse three-vessel spasm and other types of coronary artery spasm [1,3]. We have observed: First, diffuse three-vessel coronary artery spasm mostly occurs spontaneously. Second, diffuse three-vessel coronary artery spasm must be considered when 12-lead ECG shows no important ST segment changes with episodes of angina. Third, it is not easy to distinguish diffuse three-vessel coronary artery spasm from other types of coronary artery spasm on the basis of history, laboratory data, or ECG findings, including exercise tests.However, despite the very difficult diagnosis, when treated with correct diagnostic work-up and medications, the prognosis is pretty good [1,3].