Tandon Varun, Mosebach Christian M, Kumar Manish, Joshi Saurabh
Internal Medicine, University of Connecticut, Farmington, USA.
Cardiology, University of Connecticut, Farmington, USA.
Cureus. 2019 Feb 25;11(2):e4134. doi: 10.7759/cureus.4134.
Vasospastic angina (VSA) is defined as spasm of the coronaries leading to transient constriction and eventual myocardial ischemia. VSA is treated typically with calcium-channel blockers (CCBs) and nitrates. However, there are times when the vasospasm is refractory to typical medications. When this occurs, unconventional treatment modalities may be employed for symptomatic relief. We present a case of a 48-year-old-male with a history of inferior ST-elevation myocardial infarction (STEMI) status post percutaneous coronary intervention (PCI) with drug-eluting stent (DES) to the distal right coronary artery (RCA), who presented with recurrent angina. The pain was described as pressure-like, substernal, radiating to both arms, and similar to his previous STEMI presentation. On presentation to the emergency room, he had an elevated serum troponin with no electrocardiogram (EKG) changes. He was taken to the cath lab where it was found that he revealed severe focal stenosis just proximal to the previously placed stent. Immediately after guidewire passage into the RCA, acute vasospasm developed, resulting in diffuse, severe stenosis, extending over previously normal segments to the proximal RCA, resolving with intracoronary nicardipine and nitroglycerin, including the initial focal stenosis. The patient was diagnosed with VSA. Unfortunately, despite optimal medical therapy, he developed refractory VSA, requiring the use of unconventional treatment methods. Our patient presented with a lesser-known phenomenon called refractory VSA, where intermittent vasospasm continues despite being on a combination of two medications. Treatment for VSA is well-documented, however, little data is available for refractory VSA.
变异性心绞痛（VSA）定义为冠状动脉痉挛导致短暂性狭窄并最终引起心肌缺血。VSA通常采用钙通道阻滞剂（CCB）和硝酸盐类药物治疗。然而，有时血管痉挛对常规药物治疗无效。当这种情况发生时，可能会采用非常规治疗方法来缓解症状。我们报告一例48岁男性病例，该患者有下壁ST段抬高型心肌梗死（STEMI）病史，曾接受经皮冠状动脉介入治疗（PCI），在右冠状动脉（RCA）远端植入药物洗脱支架（DES），此次因复发性心绞痛就诊。疼痛描述为压榨样，位于胸骨后，放射至双臂，与他之前的STEMI表现相似。就诊于急诊室时，他的血清肌钙蛋白升高，但心电图（EKG）无变化。他被送往导管室，在那里发现他在先前放置的支架近端有严重的局灶性狭窄。在导丝进入RCA后立即发生急性血管痉挛，导致弥漫性、严重狭窄，延伸至先前正常的节段直至RCA近端，经冠状动脉内使用尼卡地平和硝酸甘油后缓解，包括最初的局灶性狭窄。该患者被诊断为VSA。不幸的是，尽管进行了最佳药物治疗，他仍出现了难治性VSA，需要使用非常规治疗方法。我们的患者出现了一种较少见的现象，即难治性VSA，尽管联合使用了两种药物，间歇性血管痉挛仍持续存在。VSA的治疗已有充分记录，然而，关于难治性VSA的数据却很少。
