Vasospastic Angina Unmasked on Repeat Coronary Angiography in a Patient Without Typical Triggers: A Case Report

Vasospastic angina (Prinzmetal angina) is a rare but clinically significant cause of chest pain that occurs due to transient coronary artery spasm, leading to myocardial ischemia. It often presents with chest pain at rest, typically during late-night or early-morning hours, and may be associated with transient ST-segment changes on an electrocardiogram (ECG) but without significant obstructive coronary disease. Typical triggers include cigarette smoking, drug use, and stress-related endothelial dysfunction. However, some patients lack traditional risk factors, complicating diagnosis. We describe a 69-year-old woman with a history of ST-elevation myocardial infarction (STEMI), hypertension, hyperlipidemia, and venous thromboembolism, who presented with left-sided chest pain, nausea, and diaphoresis. Initial workup suggested a non-ST-elevation myocardial infarction (NSTEMI) with elevated cardiac troponin, yet urgent coronary angiography showed no obstructive lesions. Persistent symptoms and further troponin elevation (>2000 ng/L) prompted a second angiography, which revealed coronary vasospasm in the proximal left anterior descending (LAD) and circumflex arteries, confirming NSTEMI precipitated by intense, prolonged vasospasm. The patient responded well to calcium channel blockers and long-acting nitrates, underscoring the need to consider vasospastic angina even in individuals without common precipitants. This case highlights the importance of repeat angiography, the role of vasodilatory therapy, and the potential for more advanced diagnostic or genetic testing to clarify underlying risk factors.