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A 39-year-old woman with gastro-oesophageal reflux disease, tobacco abuse and family history of premature coronary artery disease (CAD) presented to the hospital reporting of new onset substernal chest pain for 4 days prior to admission. She experienced multiple episodes of chest pain at rest and exertion without aggravating or alleviating factors. Each episode lasted for 15 min with radiation to the left arm. Associated symptoms included left arm tingling sensation, diaphoresis, dry mouth, blurry vision and dizziness. Physical examination was unremarkable. Initial vital signs were significant for tachycardia with heart rate in 130 s. ECG showed sinus tachycardia and ST-segment elevations in leads V1, V2 that were transient (figure 1). Serial cardiac biomarkers showed up-trending troponin levels at 2.05 ng/mL (normal range: 0.00–0.04 ng/mL). Patient was started on heparin drip, aspirin, statin, beta-blocker and scheduled for urgent cardiac catheterisation.
Transthoracic echocardiogram revealed a preserved ejection fraction of 60% without regional wall motion abnormalities. Coronary angiography showed severe (80%–90%) proximal stenosis of left anterior descending (LAD) with normal left circumflex and right coronary arteries (video 1). Our differential diagnosis included non-ST-segment elevation myocardial infarction (NSTEMI) and coronary vasospasm. An amount of 200 μg of intracoronary nitroglycerin was administered in the left coronary system. Repeated coronary angiography after adequate time was given to allow the nitroglycerin to percolate, which revealed persistence of the lesion (video 2). Given these angiographic findings, we decided to proceed with intervention of the LAD. We first inserted a 7-french XB 3.0 guide catheter into the left coronary artery. As we were inserting a run-through interventional wire into the LAD, the lesion was not appreciated anymore in the proximal LAD, hence increasing the suspicion of coronary vasospasm. (video 3). The patient was asymptomatic during cardiac catheterisation. Decision was made to perform optical coherence tomography (OCT)-guided intravascular imaging of the LAD to assess intraluminal pathology in the LAD. OPTicross OCT catheter was inserted and intravascular images of the LAD were obtained, which revealed absence of CAD or plaque rupture in the LAD (video 4). The diagnosis of vasospastic angina (VSA) was, hence, confirmed.
Patient was started on calcium channel blockers. She was strongly advised to quit smoking and has been asymptomatic in outpatient follow-up visits.
OCT can help study pathology of coronary arterial wall at the vasospasm sites in patients with VSA.1 2 Luminal irregularity, intraluminal thrombi and intimal erosion are the most common morphological features of coronary artery spasm sites visualised using OCT in patients with VSA.3–6 VSA can occur in angiographically normal or near-normal coronary arteries.
Above case represents VSA as the cause for acute coronary syndrome confirmed with OCT, which helped in ruling out atherosclerotic CAD and plaque rupture. To evaluate culprit lesion, OCT was performed, which helped in confirming the mechanism of acute coronary syndrome in our patient.7 Our patient had normal coronary arteries at the vasospasm sites on OCT. Troponin elevation can be seen in both coronary vasospasm and NSTEMI.8
Optical coherence tomography (OCT) can be used to confirm the mechanism of acute coronary syndrome.
OCT reveals coronary artery wall microstructure at vasospastic sites.
Coronary vasospasm and non-ST-segment elevation myocardial infarction can both cause elevation of troponin and present with typical features of chest pain.
Coronary vasospasm is an uncommon presentation of acute coronary syndrome. It is less common than typical angina caused by atherosclerotic disease. It should be one of the leading differentials when younger age group patients present with chest pain.
Cigarette smoking is a major risk factor in vasospastic angina and coronary artery disease.
Contributors AK rounded on the patient on the general cardiac floor. YA and JKK performed a cardiac catheterisation on the patient. PKP performed the literature search and helped in writing up the case report.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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