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Coronary Vasospasm in ST-Segment Elevation Myocardial Infarction with Non-Obstructive Coronary Arteries

Author : H. Lim, W. Aryadana
Upload Date : 19-04-2018

Introduction: Myocardial infarction with non-obstructive coronary arteries (MINOCA) currently known as important myocardial infarction sub-group with estimated frequency 1% - 15%. Usually occur before 50 years old without previous angina or myocardial infarction, and maybe without risk factors for ischemic heart disease (IHD). MINOCA has been reported to be due to plaque disruption, plaque erosion, vasospasm, embolism, spontaneous coronary dissection, takotsubo syndrome, catecholamine toxicity, and autonomic dysfunction.

Case Illustration: Patient male 50 years old, admitted with increasing left sided chest pain, radiating to left back with epigastrium discomfort 11 hours prior admission. Symptoms felt at rest, with no dyspnea on effort and orthopnea. Patient is active smoker and denied history of hypertension, diabetes mellitus, dyslipidemia and prior heart disease. Electrocardiography (ECG) showed ST elevation in lead II, III, aVF with T wave inversion in V1 – V2. Laboratory data showed creatine kinase (CK) – MB of 21.30 ng/ml, cardiac troponin T of 584 ng/ml. Emergency coronary angiography showed no significant stenosis lesion, with right coronary artery (RCA) diameter smaller than left coronary arteries. Isosorbide dinitrate injected into coronary artery than showed dilation of RCA diameter with residual spasm at RCA ostium and resolved in few seconds.

Discussion: Coronary vasospasm, also known as Prinzmetal angina is one of the most frequent MINOCA mechanism. Predisposing factors of spasm included smoking, alcohol intoxication, cocaine abuse, hypomagnesemia, insulin resistance, hyperventilation, ergotamine, and cold stimulation. Sublingual nitrates administration are the agents of choice and effectively relieve acute vasospasm. Calcium antagonist now considered as agents of choice for therapy and preventing variant angina. Factors associated with recurrence of coronary spasm should be avoided and patient should encourage to smoking cessation.

KEYWORDS : myocardial infarction, coronary vasospasm, prinzmetal angina.


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