A moment of spasm: Angiographic evidence of vasospastic angina

A 61-year-old hypertensive gentleman presented to the Cardiology clinic with the complaint of chest heaviness on exertion for the last 3 months. Initially, the discomfort was perceived only while climbing more than 2 flights of stairs (Canadian Cardiovascular Society class II); however, over the last month, his symptoms had aggravated such that he had to take rest after walking even 200 meters on level ground (CCS class III). He was an active smoker (60 pack years) with Chronic Obstructive Pulmonary Disorder (COPD) on regular bronchodilator therapy (Formoterol in metered dose inhaler). His general physical examination was grossly unremarkable. Electrocardiogram showed normal sinus rhythm with < 1 mm J point elevation in leads II, III and AVF (Figure 1A). Transthoracic echocardiogram showed global hypokinesia of the left ventricle with an ejection fraction of 46% (modified Simpson’s method). He was taken up for conventional coronary angiogram through the right transracial access. Following transracial access, the patient began complaining of chest heaviness similar to that perceived on exertion. While the left coronary arteries showed only mild plaque without any significant stenosis, the Right Coronary Artery (RCA) showed diffuse narrowing across the entire length of the vessel (Figure 1B). A suspicion of diffuse vascular spasm was made, and 200 mcg of intracoronary nitroglycerine was administered. The subsequent angiogram showed relief of vascular spasm with only mild plaque in the proximal RCA without any flow-limiting stenosis (Figure 1B). The patient also reported immediate relief of his symptoms, and thus, a diagnosis of vasospastic angina was made. As the patient was on bronchodilator therapy for COPD, a provocation test with acetylcholine was deferred. The patient was discharged on oral isosorbide dinitrate (2.6 mg twice daily) and sustained release diltiazem (60 mg once daily). At the 3-month follow-up, the patient reports complete freedom from symptoms and a good functional capacity.