Coronary arteriovenous fistula with vasospastic angina

A 50-year-old man was admitted to our hospital because of chest pain. Twenty-four-hour ECG recording demonstrated ST-segment depression and elevation at the time of spontaneous angina. During treadmill exercise test, the patient developed chest pain with ST-segment depression in leads V4 to V6. After the administration of nifedipine (10 mg), the patient was able to reach up to the maximum predicted heart rate without anginal symptoms and ST-T changes. Coronary arteriogram demonstrated 50% stenosis at the proximal portion of the left anterior descending artery (LAD) and two small fistulas originated from LAD to pulmonary artery. Spasm was induced at the proximal portion of LAD by the hyperventilation. If patients with coronary arteriovenous fistula (CAVF) have symptoms, elective CAVF ligation has been recommended. However, this case suggests that coronary spasm could be one of the cause of angina pectoris in patients with CAVF. Elective CAVF ligation must be carefully indicated in CAVF patients with angina pectoris.