Unmasking Vasospastic Angina Pectoris Using Dobutamine Stress-Echocardiography

A 50 years old man was presented to our emergency department complaining of persistent retrosternal chest pain in the last 3 hours. He described similar episodes in the past couple of years. His ECG showed negative T-Waves in the precordial leads (V2-V6) with minimal T-wave changes in the peripheral leads. His echocardiographic findings were within normal. High sensitive Troponin was minimally elevated with normal creatinine kinase (CKMB). Angiographically we identified a coronary artery disease with intermediate ostial LAD stenosis with a negative iFR value (0.98). A complementary cardiac MRI excluded any relevant pericardial and myocardial diseases. We carried out stress echocardiography trying to reproduce his subjective symptoms and to re-assess the clinical findings. Directly before the investigation, we observed a complete recovery of the T-wave changes. During the investigation, starting from stage 3, he reported severe chest pain similar to his recurrent experience. In the ECG we observed horizontal precordial ST-segment depression. Echocardiographically we saw apical and anteroseptal hypokinesia. The patient was given sublingual nitroglycerin with complete recovery of his ECG, echocardiographic findings and chest pain. He was sent home on calcium canal blockers and thorough advice on lifestyle modification.