J Cardiovasc Interv.  2022 Apr;1(2):90-95. 10.54912/jci.2022.0004.

Staged Spasm Provocation Test Without Coronary Stenting in a Patient Presenting With ST-Segment Elevation Myocardial Infarction

• Cho KH
• Kim MC
• Sim DS
• Kim JH
• Ahn Y
• Jeong MH
• Hong YJ

• KMID: 2561246
• DOI: http://doi.org/10.54912/jci.2022.0004

Abstract

Plaque erosion is a major cause of acute coronary thrombosis. This might be due to a combination of several factors, including endothelial, fluid dynamics, systemic, and vasomotion factors, and spasm. However, the extent to which vasospasm contributes to the development of plaque erosion in patients with acute coronary syndrome is unclear. We present an educational case of an ST-segment elevation myocardial infarction, successfully managed medically under the guidance of intracoronary optical coherence tomography (OCT) and staged vasospasm provocation test. A 53-year-old male presented with acute chest pain associated with inferior-lead ST-segment elevation. After immediately arriving at our hospital, ventricular fibrillation occurred, followed by defibrillation. Emergency coronary angiography (CAG) revealed moderate to severe stenosis of the middle right coronary artery. OCT demonstrated intraluminal thrombi without definitive plaque rupture, suggesting plaque erosion. After 3 days, we performed an ergonovine provocation test that revealed near-total occlusion in the previous stenotic site of the right coronary artery at a low level of intracoronary ergonovine of 10 mg. OCT revealed resolved thrombi with an intact fibrous cap. The minimal lumen area was 3.65 mm 2 . After the patient-physician discussion, we decided to treat the lesion medically. After 6 months, CAG revealed no significant interval changes compared to the previous examination. After 12 months, he was free of chest symptoms and cardiovascular events. The staged spasm provocation test may be beneficial for the proper management of selected patients with acute coronary thrombus in whom OCT demonstrates plaque erosion at the culprit lesion.

Keyword

ST elevation myocardial infarction; Optical coherence tomography; Spasm; Coronary occlusion