Author + information
- Received November 2, 2009
- Accepted November 13, 2009
- Published online April 1, 2010.
- Rabih R. Azar, MD, MSc⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. Rabih R. Azar, Division of Cardiology, Hôtel Dieu de France Hospital, Achrafieh, Beirut, Lebanon
The patient is a 65-year-old man who was complaining of chest pain induced by heavy exercise but sometimes occurring at rest. An exercise stress test was mildly positive electrically (1 mm ST-segment depression at 9 min of exercise and at a heart rate of 92% of the maximally predicted heart rate for age). The patient was treated medically. A few months later, he presented to the outpatient clinic with more severe and more frequent chest pain occurring mainly at rest. He was referred for coronary angiography, which revealed a 70% stenosis in the mid left anterior descending artery (LAD) (Figs. 1A and 1B). The lesion did not significantly improve with intracoronary nitroglycerin and was treated by implantation of a LIBERTE 3.5 × 16 mm bare-metal stent (Boston Scientific, Natick, Massachusetts), which was redilated in its proximal segment by a 4 × 10 mm noncompliant balloon at 18 atm. The result was excellent, with a negative residual stenosis and a normal flow (Fig. 2). The patient continued to experience chest pain occurring mainly in early morning and awakening him from sleep. The pain was described as being more severe than before stenting. Repeat coronary angiography was performed 3 days after the initial procedure (see Online Video 1 for the first 2 runs) and revealed diffuse spasm involving all the left coronary circulation (including the left main), except in the segment of the LAD where the stent was present (Fig. 3,Online Video 1). After intracoronary nitroglycerin, the spasm resolved (Fig. 4,Online Video 1). The patient was placed on oral nitroglycerin and calcium channel blocker and remains pain-free more than 8 months after follow-up.
The stenosis in the LAD of the patient was in retrospect, not the cause of the symptoms, which were due to spasm. These images demonstrate that spasm can be diffuse and can involve all the coronary circulation including the left main. They also demonstrate that spasm can occur either proximal or distal to a stented segment, which explains the “inefficacy” of stenting in the treatment of spastic angina.
For a supplementary video and its legend, please see the online version of this article.
- Received November 2, 2009.
- Accepted November 13, 2009.
- American College of Cardiology Foundation