High-Risk Vasospastic Angina With Recurrent Ischemic and Arrhythmic Events: A Case Report

Vasospastic angina can cause myocardial infarction and malignant ventricular arrhythmias, but a persistent coronary occlusion in a patient with established vasospasm creates an acute diagnostic and procedural dilemma. A man with recurrent troponin-positive presentations and prior non-obstructive coronary angiography developed 99% mid-left anterior descending artery narrowing in 2024 that markedly regressed after intracoronary nitrate; ergonovine provocation was subsequently positive. In April 2026, at age 42, he presented with anterior ST-segment elevation myocardial infarction after irregular use of vasodilator therapy. Angiography showed total occlusion of the left anterior descending artery at the previously nitrate-responsive segment. Intracoronary nitrate did not restore flow, and ventricular fibrillation occurred during the procedure. Bailout drug-eluting stent implantation restored flow. A proximal right coronary artery occlusion was also identified during the same procedure and treated with stenting. In June 2026, angiographically confirmed stent thrombosis required repeat percutaneous coronary intervention; an implantable cardioverter-defibrillator was subsequently implanted after multidisciplinary review. This case highlights the need to consider superimposed thrombotic or structural mechanisms when coronary occlusion in a patient with established vasospastic angina does not resolve after intracoronary nitrate. Bailout revascularization may be necessary when flow cannot be restored in a hemodynamically unstable patient, but it does not eliminate the underlying vasomotor disorder.