Clinical Images

Prinzmetal Angina Mimicking Severe Three-Vessel Coronary Artery Disease

Ziad Dahdouh, MD1,2 and Tahir Mohamed, MD1

Ziad Dahdouh, MD1,2 and Tahir Mohamed, MD1

J INVASIVE CARDIOL 2020;32(9):E240-E241. 

Key words: acute coronary syndrome, coronary vasospasm, Prinzmetal angina, vasodilators

A 64-year-old male with a history of diabetes mellitus and hypertension presented to our institution for recurrent angina occurring mainly at rest. He had no history of current or prior smoking, cocaine, or other drug abuse. Electrocardiogram (ECG) and echocardiography were normal. It was agreed with the patient to proceed with elective coronary angiogram. The procedure was performed through right radial access. The first artery to be engaged was the right coronary artery (RCA) (Figure 1A; Video 1), which was the dominant artery and tortuous. It showed long and severe narrowing at the distal segment with Thrombolysis in Myocardial Infarction (TIMI) 2 flow. During the procedure, the patient suddenly developed chest discomfort concomitantly with ischemic ECG changes. Hemodynamic parameters remained stable. The left coronary system showed significant narrowing to the left circumflex (LCX) system at the level of the second obtuse marginal (OM2) branch (Figure 1B; Video 2) and total occlusion of the mid left anterior descending (LAD) coronary artery (Figure 1C; Video 3). Intracoronary nitrate injection was performed. Immediate pain relief occurred and the ECG normalized. Further selective coronary injections showed patent LAD (Figure 1D; Video 4) with no underlying significant obstruction, and the narrowing to the OM2 branch (Figure 1E; Video 5) and distal RCA (Figure 1F; Video 6) disappeared. The caliber of the LCX system and the RCA became larger, and TIMI flow improved. Vasodilator treatment with calcium-channel blockers was initiated, and the patient remained symptom free at 1-year follow-up exam. 

Coronary artery vasospasm, or Prinzmetal angina, is a constriction of the coronary arteries that can cause complete or near-complete occlusion of the vessel. It remains a challenging diagnosis of spontaneous brief episodes of chest pain, and is usually misinterpreted as acute coronary syndrome. Usually, Prinzmetal angina affects only one coronary vessel; however, in the case herein, it occurred simultaneously in three coronary arteries, and was totally relieved after nitrate administration.

View the Supplemental Video Series Here

From the 1Heart Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; and 2Department of Interventional Cardiology, University Hospital of Caen, Caen, France.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted December 6, 2019.

Address for correspondence: Ziad Dahdouh, MD, Heart Center, King Faisal Specialist Hospital & Research Center, Zahrawi St, Al Maather, Al Maazer, Riyadh 12713, Saudi Arabia. Email: