Vasospastic angina – myocarditis imitation: a case report

    Authors

    Keywords

    vasospastic angina, variant angina, myocarditis, diagnosis

    DOI

    https://doi.org/10.15836/ccar2019.53

    Full Text

    Case report : 45-year-old woman was hospitalized for severe chest pain. Her medical problem began four months earlier. ECG and echocardiographic findings were normal. Stress test was stopped because of chest pain at 8 METs. At the time of two-minute chest pain, the ECG recorded intermittent left branch block ( Figure 1 ). The 24h Holter ECG showed the frequency dependent left bundle branch block (LBBB) but no chest pain episode. MSCT coronary artery detected normal coronary arteries. Cardiac MR was suggestive to myocarditis. Troponin and inflammatory parameters during the four months of follow-up remained normal. Considering the persistence of symptoms, coronary angiography was performed showing normal epicardial arteries. During angiography, the patient experienced chest pain at the time of right coronary artery (RCA) probing, and coronary artery spasm of the proximal RCA was obvious at the time ( Figure 2 ). After the nitroglycerin bolus application, spasm disappears ( Figure 3 ) and chest pain released. During the coronary angiography there was no ST-segment elevation, nor intermittent LBBB. Vasospastic angina has been diagnosed. The patient was further treated with calcium antagonists and long-acting nitrates resulting in clinical improvement. Stress test: Intermittent left bundle branch block during chest pain episode. Coronary angiography: right coronary artery vasospasm during chest pain episode. Coronary angiography after nitrate application. Discussion : Early diagnosis of variant angina is crucial to avoid major cardiac events ( 1 ). In the case of large coronary artery spasm, the ECG can show impermanent ST elevation. LBBB was observed temporarily in our patient during stress test concomitant with chest pain but not in the 24h Holter ECG recording. Coronary vasospasm and myocarditis are both recognized mimics of ST-segment elevation myocardial infarction with normal coronary arteries. The occurrence of both pathologies in the same patient has rarely been described ( 2 ). Our patient had no troponin increase recorded, and no inflammatory parameters. It is important to note that the diagnostic sensitivity and specificity of the CMR for pericarditis is under 100% ( 3 ). The case confirms the complexity of vasospastic angina diagnosis, and the importance of understanding the diagnostic imaging limitations.

    Cardiologia Croatica
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    Vasospastic angina – myocarditis imitation: a case report

    Extended Abstract
    Issue3-4
    Published
    Pages53-54
    PDF via DOIhttps://doi.org/10.15836/ccar2019.53
    vasospastic angina
    variant angina
    myocarditis
    diagnosis

    Authors

    Blanka Glavaš Konja*ORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Vlatka Rešković LukšićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Joško BulumORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Martina Lovrić BenčićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Marija ManceORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Zvonimir OstojićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Lada BradićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Davor RadićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Tea ŠimončekORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Jadranka Šeparović HanževačkiORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia

    Full Text

    Case report : 45-year-old woman was hospitalized for severe chest pain. Her medical problem began four months earlier. ECG and echocardiographic findings were normal. Stress test was stopped because of chest pain at 8 METs. At the time of two-minute chest pain, the ECG recorded intermittent left branch block ( Figure 1 ). The 24h Holter ECG showed the frequency dependent left bundle branch block (LBBB) but no chest pain episode. MSCT coronary artery detected normal coronary arteries. Cardiac MR was suggestive to myocarditis. Troponin and inflammatory parameters during the four months of follow-up remained normal. Considering the persistence of symptoms, coronary angiography was performed showing normal epicardial arteries. During angiography, the patient experienced chest pain at the time of right coronary artery (RCA) probing, and coronary artery spasm of the proximal RCA was obvious at the time ( Figure 2 ). After the nitroglycerin bolus application, spasm disappears ( Figure 3 ) and chest pain released. During the coronary angiography there was no ST-segment elevation, nor intermittent LBBB. Vasospastic angina has been diagnosed. The patient was further treated with calcium antagonists and long-acting nitrates resulting in clinical improvement. Stress test: Intermittent left bundle branch block during chest pain episode. Coronary angiography: right coronary artery vasospasm during chest pain episode. Coronary angiography after nitrate application. Discussion : Early diagnosis of variant angina is crucial to avoid major cardiac events ( 1 ). In the case of large coronary artery spasm, the ECG can show impermanent ST elevation. LBBB was observed temporarily in our patient during stress test concomitant with chest pain but not in the 24h Holter ECG recording. Coronary vasospasm and myocarditis are both recognized mimics of ST-segment elevation myocardial infarction with normal coronary arteries. The occurrence of both pathologies in the same patient has rarely been described ( 2 ). Our patient had no troponin increase recorded, and no inflammatory parameters. It is important to note that the diagnostic sensitivity and specificity of the CMR for pericarditis is under 100% ( 3 ). The case confirms the complexity of vasospastic angina diagnosis, and the importance of understanding the diagnostic imaging limitations.