Hyperventilation-Induced Coronary Vasospasm in an Asthmatic Patient With ST-Segment Elevation and Intramyocardial Hematoma

Figure 1. ECG Findings During the Hospital Course (A) Initial ECG showing sinus tachycardia, P-pulmonale, and right bundle branch block. (B) Repeated ECG demonstrating ST-segment elevations in leads II, III, and aVF, with reciprocal depressions in leads I, aVL, and V2 through V5. ECG = electrocardiogram.

Figure 2. Emergency Transthoracic Echocardiography Emergency transthoracic echocardiography showing transmural hyperechogenicity of the basal posterior segment of the left ventricle (LV) with preserved myocardial thickness (arrows).

Figure 3. Urgent Coronary Angiography Urgent coronary angiography revealing a normal left anterior descending artery (LAD), a dominant left circumflex coronary artery (LCx) without stenoses but with slow flow, and a minor right coronary artery (RCA) with an intermediate (40%-50%) stenosis distal to the right ventricular branch (arrow).

Figure 4. Electrocardiography During a Noninvasive Hyperventilation Test No ST-segment changes were observed during normal breathing (top). In the sixth minute of the recovery phase, asymptomatic ST-segment elevations appeared in the inferior leads (bottom).

Figure 5. Repeated Coronary Angiography During Catheter Manipulation Repeated coronary angiography during catheter manipulation in the left coronary system led to diffuse vasospasm, resulting in >90% stenosis in the mid- and distal left circumflex coronary artery (LCx) (arrows) (A), accompanied by chest pain and ST-segment elevations in the inferior leads (C). Complete resolution of the spasm occurred after administration of 200 μg of intracoronary nitroglycerin (B). LAD = left anterior descending artery.

Figure 6. Optical Coherence Tomography of the Left Circumflex Coronary Artery Optical coherence tomography of the left circumflex coronary artery revealed multilayered, healed plaques at the site of spasm (arrow) (A), with lumen irregularity and microchannels (arrows) (B).

Figure 7. Mid-LCx Focal Vasospasm After OCT After optical coherence tomography, spontaneous recurrence of focal vasospasm was observed in the mid-LCx (arrow) (A), which was relieved with intracoronary nitroglycerin (B). Abbreviations as in Figure 5.

Figure 8. Cardiac Magnetic Resonance Imaging Cardiac magnetic resonance imaging revealed a 20 × 8 mm lesion in the basal inferolateral segment of the left ventricle (LV) corresponding to the hyperechogenic zone on echocardiography. The lesion appeared centrally hyperintense with a hypointense rim on cine sequences (SSFP 2-chamber [2CH], SSFP 3-chamber [3CH], and SSFP short-axis [SA]) (circles and arrow). T2-weighted black-blood (T2BB) imaging showed hyperintensity (arrow), whereas first-pass perfusion imaging demonstrated a complete perfusion defect (arrow). T2∗ sequences revealed hypointensity, consistent with an intramyocardial hematoma (T2∗) (arrow). Ao = aorta; LGE = late gadolinium enhancement; SSFP = steady-state free precession.

Figure 9. Computed Tomography of the Chest Computed tomography of the chest showing morphological changes (micronodular and macronodular lesions with varying degrees of cavitation) (arrows), consistent with active pulmonary tuberculosis.

Visual Summary. Multimodality Approach to Diagnosing Coronary Vasospasm and Intramyocardial Hematoma Multimodality approach to diagnosing coronary vasospasm and intramyocardial hematoma in a patient with asthma–chronic obstructive pulmonary disease overlap syndrome (ACOS) and pulmonary tuberculosis. Circles and arrows indicate the key findings and point to the specific locations of these findings. CMR = cardiac magnetic resonance; CT = computed tomography; Echo = echocardiography; LV = left ventricle; NTG = nitroglycerin; OCT = optical coherence tomography.