Occlusive Multivessel Coronary Vasospasm Causing Cardiac Arrest and ST-Segment Elevation in Nonobstructive Coronaries
Gabriela Barsante Nicolela1, Pedro Henrique Ferro de Brito1, Haik N Mekhitarian1
1Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil.
Background:
Coronary vasospasm is an uncommon but potentially fatal cause of ST-segment elevation myocardial infarction with nonobstructive coronary arteries (MINOCA), and is easily missed when structural disease coexists.
Case Summary:
A 63-year-old man with heart failure with reduced ejection fraction, chronic atrial fibrillation, Stanford type B aortic dissection, and nonobstructive coronaries 3 months earlier presented with decompensated heart failure. Peri-Valsalva, he sustained ventricular fibrillation arrest requiring prolonged resuscitation; post-return of spontaneous circulation electrocardiogram showed inferior ST-segment elevation. Aortography excluded retrograde flap extension; angiography revealed right coronary occlusion with left-system spasm, all reversed by intracoronary nitroglycerin (600 μg, TIMI flow grade 3). Cardiac magnetic resonance confirmed transmural inferior infarction; calcium-channel blockade followed.
Discussion:
Coronary vasospasm is an under-recognized, potentially fatal functional cause of MINOCA; registries show vasospastic arrest survivors face high recurrence. A recent nonobstructive angiogram excludes neither spasm nor infarction, and coexisting aortic dissection mandates ascending aortography first.
Take-Home Message:
Consider occlusive vasospasm in ST-segment elevation with previously nonobstructive coronaries; exclude aortic causes, then use intracoronary nitroglycerin diagnostically and therapeutically.
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