Spontaneous Left Main and Right Coronary Artery Spasm in a Patient With Vasospastic Angina

Intracoronary injection of nitroglycerine can prevent unnecessary percutaneous coronary intervention

Background

Despite the recommendation of the current guidelines, intracoronary administration of nitroglycerine during coronary angiography is often neglected. We investigated the effect of intra-coronary nitroglycerin on the relief of coronary artery stenosis in the candidates for percutaneous coronary intervention (PCI).

Methods

We included patients with angina pectoris or myocardial infarction who were candidates for PCI. In the coronary angiography, the culprit vessel involved was evaluated, and bolus nitroglycerin at a dose of 25–200 mcg was injected into the affected coronary artery. A significant change in the percentage of coronary artery stenosis was considered a positive response, and these patients were then compared with patients who did not have a substantial change in the percentage of stenosis at the same time. Univariate analysis and then multivariate logistic regression analysis was performed to determine the predictors of response to intracoronary nitroglycerin.

Results

Among 360 patients, 27 (7.5%) responded to nitroglycerine, and 333 (92.5%) were non-responsive. The mean age of patients was 60.2 ± 11.6 years, ranging from 23 to 93 years, and 265 (73.6%) were men. The study groups were not significantly different in the baseline demographic characteristics. The presence of multivessel disease (Odds ratio (OR) = 16.26, 95% confidence interval (CI):2.07–127.6; P = 0.008) and stenosis in the left circumflex artery (OR = 3.62, 95% CI: 1.03–12.70; P = 0.044) were the independent predictors for nonresponse to nitroglycerine, leading to PCI.

Conclusion

In some cases, especially those without multivessel diseases, intracoronary nitroglycerine administration can efficiently relieve coronary stenosis and prevent unnecessary PCI.

A Rare Case of Cardiogenic Shock Following Severe Multivessel Coronary Vasospasm

Prinzmetal's angina occurs following spasms in a single or multiple vascular beds, resulting in a typical chest pain and an ST-segment elevation in electrocardiography (ECG). It can lead to life-threatening arrhythmias and sudden cardiac death. We describe a 37-year-old woman who was admitted with a typical chest pain and hypotension. Her initial ECG showed an ST-segment elevation in the inferior and precordial leads. She was transferred to the catheterization unit, where coronary angiography illustrated multivessel spasms. The spasms were relieved with a nitroglycerin injection. She was discharged with stable hemodynamics 7 days later, and at 1 month's follow-up, no recurrent attack was detected.