Tomlinson James S, Patel Amit, Levy Terry
The Royal Bournemouth Hospital, Castle Lane East, Bournemouth, Dorset BH7 7DW, UK.
Eur Heart J Case Rep. 2021 Feb 16;5(2):ytab015. doi: 10.1093/ehjcr/ytab015. eCollection 2021 Feb.
Coronary vasospasm can present like an acute coronary syndrome (ACS) with an intense vasoconstriction resulting in total or near-total occlusion of one or more of the coronary vessels. Definitive diagnosis can be made by intracoronary provocation testing.
A 37-year-old Caucasian male and smoker was admitted with chest pain. Highly sensitive troponin-I was positive at 63 ng/L (99th percentile upper reference limit, <15 ng/L) with a repeat value of 45 ng/L three and a half hours later which was of clinical significance. Serial electrocardiography (ECG) showed no ischaemic changes. Coronary angiography revealed several distal and side branch stenoses; however, angiographic appearances were atypical of coronary plaque. A differential diagnosis of spontaneous coronary artery dissection was suspected although the patient was pain free during the procedure. Computed tomography coronary angiography (CTCA) demonstrated normal coronary arteries, confirmed on repeat invasive coronary angiography. Cold pressor testing was unsuccessful in reproducing vasospasm. Acute coronary syndrome treatment was discontinued, he received smoking cessation advice and Amlodipine 5 mg daily was started. He has experienced no further episodes of cardiac chest pain on follow-up consultation 7 months later.
This is an unusual case of persistent, extensive coronary vasospasm in a patient without ongoing chest pain or ischaemic ECG changes. Intracoronary nitrates are usually effective at relieving coronary spasm. Cold pressor testing has poor sensitivity for diagnosing vasospasm when compared to intracoronary provocation testing using either acetylcholine or ergonovine. Multi-slice CTCA may help to discriminate coronary plaque from coronary vasospasm when there is diagnostic uncertainty.
冠状动脉痉挛可表现为急性冠状动脉综合征（ACS），伴有强烈的血管收缩，导致一根或多根冠状动脉完全或近乎完全闭塞。通过冠状动脉内激发试验可做出明确诊断。
一名37岁的白种男性吸烟者因胸痛入院。高敏肌钙蛋白I为63 ng/L（第99百分位上限参考值，<15 ng/L）呈阳性，三个半小时后复测值为45 ng/L，具有临床意义。系列心电图（ECG）未显示缺血性改变。冠状动脉造影显示有几处远端和侧支狭窄；然而，血管造影表现并非典型的冠状动脉斑块。尽管患者在手术过程中无疼痛，但仍怀疑为自发性冠状动脉夹层。计算机断层扫描冠状动脉造影（CTCA）显示冠状动脉正常，再次进行有创冠状动脉造影得以证实。冷加压试验未能诱发血管痉挛。停止急性冠状动脉综合征治疗，给予戒烟建议并开始每日服用5毫克氨氯地平。7个月后的随访咨询中，他未再出现心脏性胸痛发作。
这是一例不寻常的病例，患者存在持续性、广泛性冠状动脉痉挛，但无持续性胸痛或缺血性ECG改变。冠状动脉内使用硝酸盐通常可有效缓解冠状动脉痉挛。与使用乙酰胆碱或麦角新碱进行的冠状动脉内激发试验相比，冷加压试验对血管痉挛的诊断敏感性较差。当存在诊断不确定性时，多层CTCA可能有助于区分冠状动脉斑块和冠状动脉痉挛。
