A rare case of extensive anterior wall myocardial infarction due to left anterior descending spasm: A case report

Coronary artery spasm is an under-recognized cause of myocardial infarction with non-obstructive coronary arteries (MINOCA) spectrum. Diagnosis often requires adjunctive testing beyond a non-obstructive angiogram. Cardiac magnetic resonance imaging (CMRI) can localize infarction and refine differentials, while intravascular imaging and coronary function testing define mechanism and guide therapy. A 48-year-old woman presented with angina, dyspnea, hypotension, and elevated troponin level. ECG showed anterior T-wave inversion, echocardiography demonstrated severe regional wall-motion abnormalities in the anterior, apical and septal segments. Angiography demonstrated non- obstructive coronary arteries. Day 2 CMRI localized a large acute anterior myocardial infarction related to the left anterior descending artery (LAD) territory and focused the workup. Day 3 Optical coherence tomography (OCT) demonstrated LAD spasm and excluded plaque rupture, erosion, thrombus, and spontaneous coronary artery dissection (SCAD), confirming epicardial spasm as the mechanism and establishing the final diagnosis of acute anterior wall MI due to isolated LAD spasm. Isolated epicardial LAD spasm can produce a large anterior MI despite angiographically normal coronaries. In this MINOCA presentation, early CMRI localized an acute LAD-territory infarct and excluded alternative causes, guiding targeted intravascular assessment. Following OCT-guided angiography, vasospasm was identified as the likely mechanism of myocardial infarction. Therapeutic strategy was limited by vasospasm and hypotension; therapy focused on calcium channel blockade, nitrates, and ivabradine, with cautious initiation of anti-remodeling agents.