J Lipid Atheroscler.  2018 Jun;7(1):68-75. 10.12997/jla.2018.7.1.68.

Successful Treatment of Coronary Spasm with Atherosclerosis Rapidly Progressing to Acute Myocardial Infarction in a Young Woman

• Han X
• Jeong MH
• Sim DS
• Kim MC
• Kim Y
• Kim JH
• Hong YJ
• Ahn Y

• KMID: 2416260
• DOI: http://doi.org/10.12997/jla.2018.7.1.68

Abstract

Variant angina pectoris (VAP) is a special type of unstable angina with coronary artery spasm as the main pathogenesis, characterized by resting chest pain, and transient ST segment dynamic changes. The development of acute myocardial infarction is not uncommon. We report a case of a 49-year-old female patient diagnosed with VAP at 2 years before who suddenly suffered severe chest pain. Troponin-I was elevated. Immediate coronary angiography showed near-total occlusion in the proximal left anterior descending artery, which was not fully dilated despite use of intracoronary nitroglycerin. Intravascular ultrasound showed focal significant stenosis with a large amount of plaque at the site of spasm and the lesion was successfully treated with drug-eluting stent placement. Intravascular imaging may be instrumental in high-risk patients with VAP who suffer recurrent chest pain despite intensive anti-spasm medications.

Keyword

Myocardial infarction; Chest pain; Ultrasonics; Variant angina pectoris

MeSH Terms

Angina Pectoris, Variant
Angina, Unstable
Arteries
Atherosclerosis*
Chest Pain
Constriction, Pathologic
Coronary Angiography
Coronary Vessels
Drug-Eluting Stents
Female
Humans
Middle Aged
Myocardial Infarction*
Nitroglycerin
Spasm*
Troponin I
Ultrasonics
Ultrasonography
Nitroglycerin
Troponin I

Figure

• 

  Fig. 1 Twelve-lead ECG showed bradycardia and T wave inversions in precordial lead. ECG; electrocardiogram.

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  Fig. 2 (A, B) CAG revealed critical spasm in the proximal LAD, and (C, D) spasm was relieved after injection of intracoronary nitroglycerin. CAG; coronary angiography, LAD; left anterior descending artery.

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  Fig. 3 (A) One month later, ECG showed ST elevation and tall T waves in V2 to V6. (B) The next day, the ECG showed deep T wave inversions in the precordial leads. ECG; electrocardiogram.

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  Fig. 4 (A, B) CAG revealed near-total occlusion in the proximal LAD. (C) There was nosignificant stenosis in the right coronary artery and (D) the lesion was not relieved despite use of intracoronary nitroglycerin. CAG; coronary angiography, LAD; left anterior descending artery.

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  Fig. 5 (A) IVUS showed that the MLA was 2.7 mm2 and mixed PB was 82% in the target lesion, (B) the distal diameter was 4.0 mm and (C) the proximal diameter was 3.5 mm. IVUS; intravascular ultrasound, MLA; minimal lumen area, PB; plaque burden.

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  Fig. 6 (A, B) Balloon angioplasty using a 3.0×15 mm balloon was done for the proximal LAD, (C) followed by stenting using a 3.5×20 mm bioabsorbable polymer everolimus-eluting stent. (D) The final angiogram showed good distal flow with good stent apposition. LAD; left anterior descending artery.

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  Fig. 7 Post-PCI IVUS showed that minimal stent area was 8.4 mm2 with decreased plaque burden in the target lesion. PCI; percutaneous coronary intervention, IVUS; intravascular ultrasound.

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