Case report Prinzmetal angina

A 67-year-old female patient and former smoker presented to the emergency room (ER) with severe onset of chest pain. Admission ECG demonstrated ST-segment elevation in the inferior leads (Figure 1a). The patient reported to have chest pain the last couple of days associated with dyspnea. Her past medical history revealed familial adenomatous polyposis since 4 years and she has had a whipple surgery. Furthermore she had polyarthritis and esophageal spasm. For the latter she had been taken nitroglycerin if required because she did not respond to calcium-channel blockers. This time chest pain was completely different in character compared to the esophageal spasm that she had experienced in the past and she had never felt dyspnea and dizziness before for which reason she presented in the ER. In the ER symptoms spontaneously resolved after some minutes and ST-segment elevation slightly disappeared in a repeated ECG. The patient was immediately brought to cath lab because of suspicion of myocardial infarction. Interestingly, emergency coronary angiography imposed narrowing of all epicardial vessels (Figure 1b) while the patient experienced chest pain and transient ST-segment elevation. After application of nitroglycerin intravenously impressive vasodilation of all vessels was observed (Figure 1c). Cardiac enzymes, which were available after cath, showed troponin, CK and CK-MB within the normal range. NTpro-BNP was slightly elevated (317 ng/l). Notably, the patient had consulted her general practitioner 2 weeks before her presentation in the emergency department, because of dizziness, pre-syncope and chest pain symptoms. A 24-h Holter-ECG monitoring had demonstrated intermittent AV-block-III. She was already scheduled for an appointment for a pacemaker (PM) implantation, which was then performed, during her current hospitalization. This clinical picture is consistent with Prinzmetal angina complicated by AV-block. The patient was treated with a calcium-channel blocker and nitroglycerin was continued. Furthermore fluvastatin was added due to potential beneficial effects on endothelial function and reduction of coronary spasm. Repeated counseling and 1-year follow-up revealed no more angina symptoms.