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Tilt Testing with Combined Lower Body Negative Pressure: a "Gold Standard" for Measuring Orthostatic Tolerance
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ST-elevation during head up tilt test: a challenging case in syncope unit.

Andreina Carbone1, Vincenzo Avitabile2, Paolo Golino3

  • 1Syncope Unit, Department of Medical Translational Sciences, University of Campania "L. Vanvitelli", Monaldi Hospital, Naples. andr.carbone@gmail.com.

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A rare vasospastic response to nitrates occurred in a patient during a head-up tilt test, causing temporary ST elevation. This paradoxical reaction in vasospastic angina patients presents a diagnostic and therapeutic challenge.

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Area of Science:

  • Cardiology
  • Clinical Medicine
  • Pharmacology

Background:

  • Vasospastic angina (VSA) is characterized by reversible coronary artery vasospasm.
  • Nitrates are typically first-line therapy for VSA, relieving coronary vasospasm.
  • Paradoxical reactions to vasodilators in VSA are uncommon but clinically significant.

Observation:

  • A 65-year-old woman undergoing a head-up tilt test experienced ST-segment elevation in inferior leads after sublingual nitrate administration.
  • Electrocardiogram changes resolved spontaneously upon returning the patient to a supine position.
  • Serial cardiac biomarkers remained negative for myocardial injury.

Findings:

  • Coronary angiography demonstrated normal epicardial coronary arteries, ruling out obstructive coronary artery disease.
  • The patient exhibited a paradoxical, transient vasospastic response to nitrates, a known trigger for angina.
  • This event highlights a rare adverse reaction to a standard VSA treatment.

Implications:

  • The findings underscore the complexity of managing VSA, particularly in patients with paradoxical nitrate responses.
  • Optimal therapeutic strategies for this specific subgroup of VSA patients require further investigation.
  • Clinicians should consider the possibility of paradoxical vasospasm when managing VSA patients on nitrate therapy.