Lethal presentations of coronary artery spasm after an event-free period of six years following initial diagnosis.

Isolated coronary artery spasm without atherosclerotic obstruction is an unusual cause of myocardial infarction (MI). A middle-aged woman presented to our institution in 2001 with acute inferior MI due to coronary artery spasm at the mid segment of the dominant left circumflex coronary artery. After being well for 6 years, she was readmitted again in 2007 with the same type of severe retrosternal chest pain. Electrocardiography (ECG) showed ST-segment elevation over the inferior leads. The chest pain resolved with sublingual nitroglycerin and emergency diagnostic coronary angiography showed normal coronary arteries. Two months later, the patient developed another episode of severe retrosternal chest pain at home, followed by cardiac arrest. An onsite ECG showed ventricular fibrillation and immediate defibrillation was carried out. She was readmitted to the hospital and recovered over the next few days. In view of the recurrent coronary artery spasm causing myocardial infarction and ventricular fibrillation, an implantable cardioverter defibrillator was implanted. The patient was well at 2-month follow up.