Coronary spasm: a case of transient ST elevation and syncopal ventricular tachycardia without angina

We report the case of a 60-year-old male with recurrent pre-syncope, referred with a provisional diagnosis of carotid sinus syndrome on the basis of a 4 s asystolic pause following carotid sinus massage. On repeat Holter monitoring there was ST-segment elevation followed by episodes of polymorphic ventricular tachycardia during a mild episode of pre-syncope. Coronary angiography showed mild right coronary artery irregularity without significant stenosis. An automatic cardioverter defibrillator was implanted and high dose combined vasodilator therapy was commenced. At follow-up 18 months after implantation, the device has recorded no episode of tachycardia and the patient reports no recurrence of symptoms.