Multivessel coronary artery spasm in pericarditis

Abstract

Dear Sir, Coronary vasospasm can result in tombstone-like ST elevations in the presence of non-obstructive coronary arteries on angiography. Coronary vasospasm has been reported to coexist with myocarditis, possibly due to endothelial dysfunction or coronary smooth muscle cell hyperreactivity. We herein describe a novel presentation of tombstone-like ST elevations that were likely from multivessel coronary vasospasm in a patient with pericarditis. A 40-year-old man with a three-day history of an infected right lower molar tooth presented to the emergency department with dysphagia, shortness of breath and right neck swelling. There was no complaint of chest pain, and he had no past medical history or any cardiac problems prior to presentation. Electrocardiography (ECG) performed at the point of admission showed typical global concave upward ST elevations with PR interval depression consistent with pericarditis (Fig. 1a). Further investigations revealed elevated inflammatory markers. Computed tomography of the neck and thorax, which was performed in view of his presentation history, showed gas gangrene in the neck communicating with the mediastinum, likely due to contiguous infection. The patient underwent surgery for his disease and received broad-spectrum antibiotics, as guided by microbiological cultures. On the sixth day of admission, diffuse tombstone-like non-territorial ST elevations were seen on ECG without any symptom or haemodynamic instability (Fig. 1b); they completely resolved after 15 minutes. There were no Q waves thereafter. The diffuse tombstone-like ST elevations recurred on the tenth day of admission and again resolved after 15 minutes. Peak serum troponin levels were marginally elevated at 0.063 mcg/L (normal < 0.040 mcg/L). The patient was under sedation and intubated for the first two weeks of his admission.

Pericarditis as a trigger for Prinzmetal angina – a case report

“…Coronary artery spasm is a multifactorial disease with an underlying mechanism still poorly understood [ 5 ]. Coronary vasospasm has been reported to coexist with myocarditis, possibly due to endothelial dysfunction or coronary smooth muscle cell hyperreactivity [ 6 ].…”

“…We do not yet know what causes vasospastic angina. However, we do know that the following are often triggers: emotional stress, exposure to extreme cold weather or a sudden drop in temperature, hyperventilation, allergic reactions (usually severe reactions that result in histamine release, sometimes referred to as Kounis Syndrome), inflammation of the coronary artery wall, smoking, some antidepressants, some anti-migraine drugs, use of cocaine, high consumption of alcohol [ 6 ]. Angina pain in vasospastic angina manifests as pain or discomfort in the chest, arm, or jaw.…”

“…Angina pain in vasospastic angina manifests as pain or discomfort in the chest, arm, or jaw. The pain is often severe but can be variable and usually occurs while at rest and early in the morning or late at night [ 6 ].…”