Angina due to coronary artery spasm after a percutaneous coronary intervention.

An 80-year-old Caucasian woman with diabetes, hypertension, dyslipidaemia, a smoking habit, and a long-standing history of stable ischaemic heart disease presented with moderate-intensity, recent-onset chest pain (Canadian Cardiology Society Class II). Seven years previously, she had undergone a percutaneous coronary intervention (PCI) with stenting of the proximal left anterior descending artery due to chronic stable angina, and, 5 years previously, a repeat revascularization with balloon angioplasty for a critical in-stent restenosis. Due to a symptomatic second-degree atrioventricular block, she also received a bicameral pacemaker. One month prior to admission, she had undergone another PCI with a drug-eluting balloon due to recurrent in-stent restenosis.

The patient reported that her chest pain was different from the angina symptoms she had experienced in the past because it did not occur during effort, but predominantly at rest and after emotional triggers. On physical examination, her heart rate was 65 b.p.m., blood pressure 146/70 mmHg, and oxygen saturation 99% while breathing ambient air. The electrocardiogram (ECG) showed a paced rhythm. Her blood cholesterol was 143 mg/dL, low-density lipoprotein 84 mg/dL, high-density lipoprotein 35 mg/dL, and blood glucose 63 mg/dL. High-sensitivity troponin and N-terminal pro-B-type natriuretic peptide levels were normal. An echocardiogram showed mild left ventricular dysfunction (left ventricular ejection fraction 50%) and a mild-to-moderate mitral regurgitation.

In your normal clinical practice, which tests would you do at this stage?

Although exercise ECG testing or myocardial perfusion imaging may be considered in this patient, based on her prior cardiovascular history with multiple revascularizations and her new symptoms, we directly opted for repeating a coronary angiography and eventually performing a functional test, suspecting a possible functional coronary abnormality causing her chest pain. The patient was already on dual-antiplatelet therapy with aspirin 100 mg once daily and clopidogrel 75 mg once daily. She was also taking simvastatin 20 mg once daily, ramipril 5 mg once daily, and bisoprolol 2.5 mg twice daily (which was discontinued 48 h before the coronary angiography). Coronary angiography showed no significant stenoses and a persistent good result of the recent PCI on the left anterior descending artery (Figure ).

Figure 1

Coronary angiography, showing no significant stenoses (A). Intracoronary acetylcholine provocation testing, showing diffuse epicardial coronary artery spasm (yellow arrows) in the mid-to-distal left anterior descending artery (B). Resolution of angina and angiographic abnormalities after nitrate administration (C).

Which tests would you perform at this point?

Considering the characteristics of the chest pain and the absence of fixed epicardial coronary stenoses, we decided to perform an intracoronary acetylcholine provocation testing. Incremental doses of 20 and 50 μg of acetylcholine were manually infused over a period of 3 min into the left coronary artery via the angiographic catheter, while heart rate, blood pressure, and 12-lead ECG were continuously monitored. After infusion of the 50 μg acetylcholine dose, the patient developed severe chest pain (recognized as similar to that experienced at home), which was associated with significant and diffuse epicardial coronary artery spasm, particularly evident in the mid-to-distal left anterior descending artery (Figure ). Both angina and angiographic abnormalities rapidly resolved after the administration of intracoronary nitrates (Figure ). ECG was uninterpretable for ST-T wave changes during the testing due to the paced rhythm. A diagnosis of vasospastic angina was made.,

Treatment

The importance of a lifestyle change, in particular, smoking cessation and regular physical exercise, was explained to the patient. It was also recommended to continue dual-antiplatelet therapy until at least 12 months from the last PCI. Both statin and angiotensin-converting enzyme inhibitor therapies were also recommended despite the fact that control of both the blood pressure and the lipid profile were also appropriate.

Based on the new diagnosis of vasospastic angina, beta-blockers (i.e. bisoprolol 2.5 mg twice daily) were definitively discontinued, as they could precipitate coronary spasm, and therapy with a calcium channel blocker (i.e. diltiazem 120 mg three times daily) was started.

One month later, the patient was asymptomatic with well-controlled heart rate and blood pressure.

Funding

The authors didn’t receive any financial support in terms of honorarium by Servier for the articles.

Conflict of interest: none declared.