Prinzmetal Variant Angina Associated with Multiple Sclerosis

Abstract

Prinzmetal variant angina is characterized by angina secondary to coronary artery vasospasm, 1 typically at rest, associated with transient ST-segment deviations.2 Further diagnostic workup using angiography may reveal coronary arteries with or without atherosclerotic narrowings.1 Multiple sclerosis (MS) is typically a relapsing-remitting neurologic disorder involving demyelinated plaques, which slow or block conduction along nerves.3 Literature search reveals one case report indicating a causal relationship between these 2 diseases. 4 We present an additional case involving a 38-year-old patient who experienced Prinzmetal variant angina during a multiple sclerosis relapse. Case ReportA 38 year-old hospitalized woman was receiving an intravenous injection of meperidine for abdominal pain when she complained of severe chest pain and pressure that radiated to her neck, jaw, and left arm. She had mild shortness of breath and diaphoresis.The patient had been admitted 2 days earlier with nausea, vomiting, and abdominal pain after starting an oral prednisone taper for a recent MS exacerbation. Magnetic resonance imaging (MRI) on admission showed multiple foci of increased T 2 signal intensity, in the periventricular subcortical distribution, consistent with MS. Two new foci were seen in the right hemisphere, one in the centrum semiovale and another in the right inferior parietal lobe, just above the calcarine fissure. These demonstrated increased signal on the diffusion images, suggesting a more acute process of demyelination. The patient denied any previous episodes of chest pain as well as any cardiac history, hypertension, hypercholesterolemia, or respiratory problems. Past medical history included MS, depression, possible seizure disorder, tonsillectomy, and appendectomy. She was adopted, and her family history is unknown. Her usual medications include 150 mg of ranitidine twice daily, 50 mg of sertraline twice daily, 100 mg of amantadine twice daily, 100 mg of carbamazepine twice daily, norethindrone and ethinyl estradiol, propoxyphene napsylate as needed, and interferon ␤1a once per week. She was married with 2 children and she had smoked Ͻ1 pack of cigarettes per week for the prior 20 years. She rarely used alcohol, and she denied any drug use or herbal medications. Ten days before admission, she had lost her father to a stroke; his funeral was 3 days before admission.When examined, her temperature was 97.4°F, pulse was 50 to 70 beats/min, blood pressure was 130/70 mm Hg, respiratory rate was 20 breaths/ min with an oxygen saturation of 99% on 2 liters of O 2 via nasal cannula. In general, she was a pleasant, healthy woman who appeared moderately uncomfortable and anxious. Results of the examination were unremarkable.Her electrocardiogram showed 1-mm ST segment elevation in leads II, III, and aVF, suggesting an acute inferior myocardial infarction. Her chest radiograph was negative for acute processes. After administration of oxygen, aspirin, 0.4 mg of sublingual nitroglycerin, heparin, and intravenous morphine...

The spectrum of acute cardiopulmonary events associated with multiple sclerosis exacerbations

“…10,39 Angina pectoris associated with MS relapses has also been reported. 40,41…”

Acute myocardial infarction with normal coronary artery (MINCA) in a patient with multiple sclerosis

“…The most known are coronary vasospasm and thromboembolic disease. Changes in autonomic neural control, changes in contractile function, locally released vasoactive mediators in contact with dysfunctional endothelium, history of smoking, mental stress and oral contraceptive use may be responsible for coronary artery vasospasm [7]. In their study, Bulkley et al [10] described the autopsy findings of nine patients with progressive systemic sclerosis and evidence of ischemic heart disease but morphologically normal coronary arteries.…”

“…Lalouschek et al [8] reported a 53-year-old woman with normal coronary arteries who had angina at rest, which was associated with myelitis of the thoracic spinal cord. Joing et al [7] reported a case of 38-year-old woman who experienced Prinzmetal variant angina during a multiple sclerosis relapse. Lappegard et al [9] reported myocardial infarction in a 45-year-old male with acute and documented inflammatory changes in the spinal cord.…”

“…Nevertheless, coronary vasospastic reactions secondary to spinal cord pathology may lead to myocardial infarction [7][8][9]. However, the number of case report descriging the relationship between myocardial ischemia and multiple sclerosis (MS) is limited and pathogenesis of this condition is still being debated.…”

Thoracic myelitis as a possible cause of myocardial infarction

“…Although myocardial infarction due to vasospasm is rare [4], it has been described [5], but to our knowledge never in connection with spinal cord lesions. One recent report describes an acute coronary syndrome in a patient with exacerbation of multiple sclerosis [6], but no images of the spinal cord were made in this case.…”