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Spontaneous Multivessel Coronary Artery Spasm: A Case Report
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A 60-year-old male presented to the emergency department of our hospital with persistent dull pain in the lower and middle sternum with generalized sweating after a heated argument with another person, and his symptoms did not resolve after 3 hours of onset. The patient had a 5-year history of hypertension, which is now under stable control. There is no history of diabetes mellitus, hyperlipidemia, or other diseases, and no habits such as smoking or alcohol consumption.
After 3 hours, his temperature was 36.8°C, blood pressure was 132/98 mm Hg, pulse was 78 beats per minute, and electrocardiogram showed ST-segment depression in leads V2-V5 of 0.1-0.2 mV; troponin T was 0.062 ng/mL (0.010-0.017 ng/mL), creatine kinase-myocardial band was 31.2 U/L (0.0-25.0 U/L); and D-dimer was 292 μg/L (< 550μg/L).
Emergency coronary angiography performed 2 hours after hospitalization showed that all coronary arteries were thin except for the left main trunk, with approximately 90% stenosis in the proximal segment of the left anterior descending artery (LAD) (Figure, A & B; blue arrows), multiple mild to moderate stenoses in the proximal and middle segments of the left circumflex artery (LCX) and obtuse marginal (OM), and moderate to severe stenoses in the proximal and middle segments of the right coronary artery (RCA) (Figure, A-C).
After intracoronary injection of 200 μg of nitroglycerin into the left coronary artery (LCA), the LCA became thicker than before and only mild stenosis remained in the proximal segment of the anterior descending branch (Figure, D & E), which we considered to be a multi-branch diffuse coronary spasm. Postoperatively, diltiazem, isosorbide mononitrate, atorvastatin, aspirin, and clopidogrel were administered, and the patient had no further episodes of chest tightness and chest pain. The coronary angiography on the fifth day of admission showed that the RCA diameter was also significantly thicker than before (Figure, F).
Intravascular ultrasound (IVUS) showed that the proximal segment of the anterior descending branch had a minimum lumen area of 6.42 mm2 with 57% plaque load (Figure, G), the proximal segment of the LCX had a minimum lumen area of 2.34 mm2 with 49% plaque load (Figure, H), and the middle segment of the right coronary had a minimum lumen area of 7.24 mm2 with 58% plaque load (Figure, I).
After discharge, the patient continued treatment with oral diltiazem, isosorbide mononitrate, atorvastatin, aspirin, and clopidogrel. There were no major adverse cardiovascular events after 15 months of follow-up.
Affiliations and Disclosures
From the 12nd Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China; 2Heart Center, Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China; 3Hangzhou Linping Hospital of Traditional Chinese Medicine, Linping, 311106, Zhejiang, China.
Drs C-j Wang and Q-c Wang served as co-first authors of the manuscript.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Funding: This research was supported by Zhejiang Province Medical and Health Science and Technology Plan Project (Grant No.2023KY053).
Address for correspondence: Ya-hui Ding, Heart Center, Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China. Email: dingyh@zjheart.com
