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Published on: September 17, 2021
Multivessel coronary vasospasm mimicking triple-vessel obstructive coronary artery disease
Vineeta Ahooja1, Deepak Thatai
1Division of Cardiology, Wayne State University, Detroit Medical Center, Detroit, MI, USA.
Insights
Spontaneous coronary artery spasm can mimic severe blockages, leading to unnecessary surgeries. Reconsidering intracoronary nitroglycerin may benefit patients with rest angina.
Area of Science:
- Cardiology
- Vascular Medicine
- Diagnostic Imaging
Background:
- Spontaneous coronary artery spasm is a significant cause of morbidity in patients with and without atherosclerotic coronary artery disease.
- Coronary vasospasm typically occurs focally and can be induced by various agents.
- Severe multivessel coronary artery spasm, mimicking obstructive coronary artery disease, is infrequently reported.
Observation:
- A patient with a history of triple-vessel coronary artery bypass graft (CABG) surgery presented with rest angina.
- Initial angiography revealed severe obstruction in all three native coronary arteries, despite patent grafts.
- Administration of intracoronary nitroglycerin resulted in the normalization of all three native coronary arteries.
Findings:
- The case highlights a diagnostic dilemma where coronary vasospasm was initially unrecognized.
- The patient underwent an unnecessary coronary artery bypass graft surgery due to a lack of clinical suspicion for spasm.
- This scenario underscores the potential for severe multivessel coronary artery spasm to be misdiagnosed as obstructive coronary artery disease.
Implications:
- The findings question the current practice of not routinely using intracoronary nitroglycerin.
- Revisiting the use of intracoronary nitroglycerin may be beneficial for specific patient groups, particularly those presenting with rest angina.
- This case emphasizes the importance of considering coronary vasospasm in the differential diagnosis of angina, even in patients with prior revascularization.
Abstract:
Spontaneous coronary artery spasm is an important cause of morbidity both in patients with atherosclerotic coronary artery disease and in those with Prinzmetal's angina. Coronary vasospasm tends to occur in focal areas in the coronary tree and can be readily induced by the use of various agents. Spontaneous severe multivessel spasm, mimicking severe obstructive coronary artery disease, has been infrequently described. The therapeutic dilemma in such a clinical situation is highlighted in our current case where an unnecessary coronary artery bypass graft surgery (CABG) was performed due to the lack of clinical suspicion of spasm. This patient presented 5 years after triple-vessel CABG with an episode of rest angina, and was initially found to have severe obstruction of all three native coronary arteries with patent grafts to the right coronary and left anterior descending arteries. After nitroglycerin injection, all three native vessels appeared large and normal. This report raises the question of whether the routine use of intracoronary nitroglycerin, largely abandoned over the past 20 years, should be revisited, at least for certain patient populations such as those with rest angina.
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