Ismayl Mahmoud, Abusnina Waiel, El Yousfi Noraldeen, Aboeata Ahmed, Sricharoen Nattapong
Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA.
Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, NE, USA.
Ann Med Surg (Lond). 2022 Apr 29;78:103691. doi: 10.1016/j.amsu.2022.103691. eCollection 2022 Jun.
Left main coronary artery (LMCA) vasospasm is rare and can cause demand-supply mismatch that can mimic coronary artery disease (CAD). This could lead to misdiagnosis and inappropriate referral for surgical intervention.
A 55-year-old woman with no cardiac risk factors presented with anginal chest pain. Vital signs were stable and physical exam was unremarkable. Chest x-ray was normal and electrocardiography (ECG) revealed sinus bradycardia with nonspecific ST-segment and T-wave changes in the inferolateral leads present on prior ECGs. Echocardiography revealed a left ventricular ejection fraction of 60-65% without regional wall motion abnormalities and cardiac troponin was within normal limits. Nuclear stress test was unsuccessful due to severe reaction to regadenoson. Subsequent invasive coronary angiography revealed an isolated 70% stenosis of the LMCA. Patient was referred for surgery, however, coronary computed tomography angiography (CCTA) prior to surgery unmasked spasm and prevented unnecessary surgery.
Coronary spasm is diagnosed clinically based on typical symptoms, transient ECG changes, and a negative stress test with no regional wall motion abnormalities on echocardiography. During episodes of spasm, coronary angiography would reveal an area of stenosis in the affected coronary segment. This could lead to a misdiagnosis of CAD and, in cases of LMCA stenosis, inappropriate referral for surgical intervention.
LMCA spasm is rare but can mimic CAD leading to misdiagnosis and unnecessary surgery. Physicians should have a high suspicion for spasm especially in patients with anginal chest pain who lack CAD risk factors. CCTA can unmask spasm and prevent unnecessary interventions.
左主干冠状动脉（LMCA）痉挛较为罕见，可导致供需不匹配，酷似冠状动脉疾病（CAD）。这可能导致误诊以及不恰当的手术干预转诊。
一名无心脏危险因素的55岁女性出现心绞痛性胸痛。生命体征稳定，体格检查无异常。胸部X线正常，心电图（ECG）显示窦性心动过缓，下侧壁导联有非特异性ST段和T波改变，先前的心电图也有此表现。超声心动图显示左心室射血分数为60 - 65%，无节段性室壁运动异常，心肌肌钙蛋白在正常范围内。核素负荷试验因对雷加昔布严重反应而未成功。随后的有创冠状动脉造影显示LMCA孤立性70%狭窄。患者被转诊进行手术，然而，术前冠状动脉计算机断层扫描血管造影（CCTA）发现了痉挛，避免了不必要的手术。
冠状动脉痉挛根据典型症状、短暂性心电图改变以及负荷试验阴性且超声心动图无节段性室壁运动异常进行临床诊断。在痉挛发作期间，冠状动脉造影会显示受影响冠状动脉节段的狭窄区域。这可能导致CAD的误诊，对于LMCA狭窄的病例，会导致不恰当的手术干预转诊。
LMCA痉挛罕见，但可酷似CAD导致误诊和不必要的手术。医生应对痉挛高度怀疑，尤其是对于无CAD危险因素的心绞痛性胸痛患者。CCTA可发现痉挛并避免不必要的干预。
