Refractory coronary artery spasm

A patient with an episode of refractory myocardial ischemia induced by ergonovine is described. The patient underwent cardiac catheterization 2 weeks after an inferior wall myocardial infarction for evaluation of recurrent rest angina. He developed severe spasm of the proximal right coronary artery in response to ergonovine which was partially relieved with nitrates and calcium channel antagonists. However, myocardial ischemia persisted, culminating in a new inferior wall infarction. The possible mechanism of continuing intense ischemia despite partial relief of the proximal right coronary spasm is discussed. It is suggested that ergonovine testing should perhaps be avoided during the early postinfarction period. Furthermore, if an ergonovine test is anticipated, beta-adrenergic blocking agents should be withheld.