case_images: PMC10045981_01
case_images: Electrocardiogram at the first admission showed sinus rhythm and early repolarization pattern with a J-wave in the inferior and V5-V6 leads.
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case_images: F1
case_images: An electrocardiogram (ECG) showed sinus rhythm and signs of early repolarization pattern with a J-wave in the inferior and V5-V6 leads (Figure 1). Dynamic ECG records showed severe sinus bradycardia, advanced atrioventricular block, ventricular escape rhythm, and ventricular fibrillation (Supplementary Figure 1).
case_images: Baseline coronary angiography at first admission showed a subtotal occlusion of the left anterior descending artery with thrombolysis in myocardial infarction 0-1 flow (A), mild-moderate stenosis in the left circumflex artery (B), and right coronary artery (C). Intravascular ultrasound showed diffused atherosclerotic plaque in the left anterior descending artery (D).
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case_images: F2
case_images: Coronary angiography (CAG) revealed a subtotal occlusion of the proximal left anterior descending (LAD) artery with antegrade thrombolysis in myocardial infarction (TIMI) 0-1 flow (Figure 2A). TIMI 3 flow (Figures 2B, C). The mid to distal LAD vessel was filled from collaterals originating from the distal RCA. Intravascular ultrasound (IVUS) was performed in LAD after balloon pre-dilation and it identified diffused atherosclerotic plaque from proximal to distal LAD (Figure 2D). Taking all these findings together, we attributed the patient's symptoms, namely, angina, syncope, and ventricular arrhythmia, to coronary artery spasm and implanted an ICD for secondary prevention of SCD (Supplementary Figure 2).
case_images: Electrocardiogram recorded on the second admission showed sinus rhythm, ST-segment elevation in the inferior and V5-V6 leads, and ST-segment depression in the lateral leads.
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case_images: F3
case_images: Physical examination, high-sensitivity troponin T, D-dimer, and head computed tomography were normal; however, ECG indicated ST-segment elevation in the inferior and V5-V6 leads when compared to the previous event (Figure 3).
case_images: Follow-up coronary angiography showed severe stenosis of the right coronary artery (A, red arrow). After administration of intracoronary nitrates, a significant recovery of vessel patency was observed (B), and a diagnosis of epicardial spasm was made (B, red arrow).
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case_images: F4
case_images: CAG showed significant luminal stenosis at mid-RCA; nevertheless, lesions in LAD and LCX were approximately unchanged when compared to the previous examination (Figure 4A). After the administration of intracoronary nitroglycerine, a remarkable recovery of RCA patency was noticed, and a diagnosis of coronary artery spasm was illustrated (Figure 4B).