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Coronary Artery Spasm: A 2009 Update

Case presentation: A 37-year-old man was admitted in the early morning hours to the emergency department after experiencing excruciating chest pain. The patient was a heavy smoker who gave a history of several previous similar but less intense episodes of pain during the past 2 years; most of them also during the early morning hours. One of his earlier attacks was associated with sensing his heart “bouncing.” In addition, he had experienced several episodes of “palpitations” without pain. On admission, ECG showed a 2 to 3 mm ST elevation which returned to baseline quickly, concomitant with his pain subsiding. Cardiac biomarkers were normal but C-reactive protein was elevated. Twenty-four hours later, a treadmill test showed good exercise capacity and no ST changes even at target heart rate. The clinical and ECG pictures pointed to the diagnosis of a vasospastic-type Printzmetal angina, and the patient responded well to calcium blockers and long-term nitroglycerin therapy and remained symptom-free throughout a 2-year follow-up.

Severe chest pain, usually without physical effort and with a concurrent ECG showing transient ST elevation, is the key for the diagnosis of coronary artery spasm (CAS) (Figure 1). Diagnosis of the silent variety of CAS is possible if the vasospastic attack occurs under medical observation or during ambulatory ECG monitoring,1 but long-term surveillance may be needed to establish the diagnosis. Exercise testing may also be helpful, although approximately equal numbers of patients show ST depression, ST elevation, or no change whatsoever during the exercise.2 Further pharmacological testing, such as provocation with intravenous ergonovine, should be used only under special conditions and with extreme care2 (Table 1). 



Figure. Surface …