An uncommon case of variant angina

This case report describes a 48-year-old woman patient with variant angina who died because of severe myocardial ischemia and cardiogenic shock, in spite of chronic therapy with nitrates and calcium-antagonists and acute intravenous administration of nitrates, calcium-antagonists and tissue-type plasminogen activator. Her Holter monitoring showed a reduction of time domain measures of heart rate variability. The hemodynamic study exhibited a normal ventriculography and angiographically normal epicardial coronary arteries. The provocative testing, performed (during intravenous therapy with nitrates and diltiazem) by intracoronary injection of progressively increasing doses of ergonovine, induced only a mild vasoconstriction of proximal left anterior descending artery, without symptoms or ST-T segment changes. This case reminds us that variant angina can be a lethal disease, confirms that a negative result of intracoronary ergonovine testing performed during intravenous therapy with nitrates and calcium-antagonists does not assure the prevention of new episodes during chronic oral therapy with the same drugs, suggests a possible prognostic value of the reduction of heart rate variability indexes and shows an unusual response to nitrate administration.