Atheroma and Coronary Artery Spasm

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Gumpanart Veerakul, MD
Sruangpat Sitakalin, MD
Kriengsak Watansawad, MD
Bhuritat Maungboon, MD
Tanyatorn Kawkaew, RN
Unchalie Sindhuwanna, RN
Adiporn Khengrang, RN
Pawana Watnaswad, RN


A 47-year-old man, a heavy smoker, developed chest pain in the morning. A few minutes before arrival at our center, he collapsed in the taxi. Ventricular brillation (VF) was documented at the emergency room. After successful cardiopulmonary resuscitation (CPR), Electrocardiogram (ECG) showed inferior ST segment elevation (STE) so he was transferred to the cardiac catheterization laboratory. Coronary angiogram showed no significant lesion in the left main (LM), anterior descending (LAD) and circumflex (Cx) arteries. The dominant right coronary artery (RCA) had a severe vasospam (> 90% luminal diameter stenosis) in the proximal part (Figure-1A). After administration of intracoronary nitroglycerine (NTG) 300 mcg, the vasospasm disappeared (Figure 1B). The lumen of RCA was enlarged and the smooth border was suggestive of insignificant plaque burden. The inferior ST elevation pattern was also normalized without Q wave. He was pain free and discharged home on aspirin and calcium antagonist. He did well but later discontinued follow-up.

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Veerakul G, Sitakalin S, Watansawad K, Maungboon B, Kawkaew T, Sindhuwanna U, Khengrang A, Watnaswad P. Atheroma and Coronary Artery Spasm. BKK Med J [Internet]. 2013 Sep. 20 [cited 2024 Jun. 13];6(1):30. Available from:
Case Report


1. Guidelines for Diagnosis and Treatment of Patients with Vasospastic Angina (Coronary Spastic Angina). Circulation J 2008;72:1239-52.
2. Prinzmetal M, Kennamer R, Merliss R, et al. Angina pectoris. The variant form of angina pectoris. Am J Med 1959;27:375-88.
3. Gensini GG, Di Giorgi S, Murad-Netto S, et al. Arteriographic demonstration of coronary artery spasm and its release after the use of a vasodilator in a case of angina pectoris and in the experimental animal. Angiology 1962;13:550-53.
4. El Menyar AA. Drug-induced myocardial infarction secondary to coronary artery spasm in teenagers and young adults. J Postgrad Med 2006;52:51-8.
5. Fernandez D, Rosenthal JE, Cohen LS, et al. Alcoholinduced Prinzmetal variant angina. Am J Cardiol 1973; 32:238-39.
6. Wasson S, Jayam VK. Coronary vasospasm and myocardial infarction induced by oral sumatriptan. Clin Neuropharmacol 2004;27:198-200.
7. Sestito A, Sgueglia GA, Pozzo C, et al. Coronary artery spasm induced by capecitabine. J Cardiovasc Med 2006; 7:136-8.
8. Bathina JD, Yusuf SW. 5-Fluorouracil-induced coronary vasospasm. J Cardiovasc Med 2010;11:281-84.
9. Shlomo S, Bajes de Luna A. Coronary Artery Spasm, A 2009 update. Circulation 2009;119:2531-34.
10. Wong A, Cheng A, Chan C, et al. Cardiogenic shock caused by severe coronary artery spasm immediately after stenting. Tex Heart Inst J 2005;32:78-80.
11. Maseri A, Mimmo R, Chierchia S, et al. Coronary spasm as a cause of acute myocardial ischemia in man. Chest 1975;68:625-33.
12. Ong P, Athanasiadis A, Hill S, et al. Coronary artery spasm as a frequent cause of acute coronary syndrome: the CASPAR (Coronary Artery Spasm in Patients with Acute Coronary Syndrome) study. J Am Coll Cardiol 2008;52: 523-27.
13. Specchia G, De Servi S, Falcone C, et al. Coronary arterial spasm as a cause of exercise-induced ST-segment elevation in patients with variant angina. Circulation 1979;59:948-54.
14. Myerburg RJ, Kessler KM, Mallon SM, et al. Lifethreatening ventricular arrhythmias in patients with silent myocardial ischemia due to coronary-artery spasm. N Engl J Med 1992;326:1451–55.
15. Sanna T, Lanza GA, Niccoli G, et al. Coronary artery vasospasm causing ventricular fibrillation. An external loop recording. Resuscitation 2009;80:393–94.
16. Roberts WC, Curry RC Jr, Isner JM, et al. Sudden death in Prinzmetal’s angina with CAS documented by angiography. Analysis of three necropsy patients. Am J Cardiol 1982;50:203–10.
17. Kaski JC, Maseri A, Vejar M, et al. Spontaneous coronary artery spasm in variant angina results from a local hyperreactivity to a generalized constrictor stimulus. J Am Coll Cardiol 1989;14:1456.
18. Lanza GA, Careri G, Cres F. Mechanism of coronary artery spasm. Circulation 2011;124:1774-82.
19. McKenna WJ, Chew CY, Oakley CM. Myocardial infarction with normal angiogram: Possible mechanism of smoking risk in coronary artery disease. Br Heart J 1982;43:493-98.
20. Sugiishi M, Takatsu F. Cigarette smoking is a major risk factor for CAS. Circulation 1993;87:76-9.
21. Takaoka K. Comparison of the risk factors for coronary artery spasm with those for organic stenosis in a Japanese population: role of cigarette smoking. Int J Cardiol 2000;72:121-26.
22. Morrow JD, Frai B, Longmire AW, et al. Increase in circulating products of lipid peroxidation (F2-isoprostanes) in smokers as a cause of oxidative damage. N Engl J Med 1995; 332:1198-03.
23. Katayama N, Nakao K, Horiuchi K, et al. Disease activities and serum C-reactive protein levels in patients with vasospastic angina pectoris. J Cardiol 2005;46:63-70.
24. Waller BF. Atherosclerotic and nonatherosclerotic coronary artery factors in acute myocardial infarction. In: Pepine CJ, ed. Acute Myocardial Infarction. Philadelphia, PA: FA Davis;1989:29-104.
25. Eliot RS, Baroldi G, Leone A. Necropsy Studies in Myocardial Infarction with Minimal or No Coronary Luminal Reduction Due to Atherosclerosis. Circulation 1974; 49:1127-31.
26. Cheitlin MD, McAllister HA, deCastro CM. Myocardial infarction without atherosclerosis. JAMA 1975;231:951-9.
27. Maseri A, L’Abbate A, Baroldi G, et al. Coronary vasospasm as a possible cause of myocardial infarction. A conclusion derived from the study of “preinfarction angina”. New Engl J Med 1978;299:1271-7.
28. Reynolds HR, Srichai MB, Igbal SN et al. (2011). Mechanisms of myocardial infarction in women with out angiographically obstructive coronary artery disease. Circulation 2001;124:1414-25.
29. Isner JM, Donaldson RF, Katsas GC. Spasm at autopsy: a prospective study [abstract]. Circulation 1983;68:III-1028.
30. Waller BF. The eccentric coronary atherosclerotic plaque: morphologic observations and clinical relevance. Clin Cardiol 1988;12:14-20.
31. Pijls NH, De Bruyne B, Peels K, et al. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med 1996;334:1703-8.
32. Watkins S, McGeoch R, Lyne J, et al. Validation of magnetic resonance myocardial perfusion imaging with fractional flow reserve for the detection of significant coronary heart disease. Circulation 2009;120:2207-13.
33. Yasue H, Mizuno Y, Harada E, et al for the SCAST (Statin and Coronary Artery Spasm Trial) Investigators. Effects of a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, Fluvastatin, on coronary spasm after withdrawal of calcium-channel blockers. J Am CollCardiol 2008;51:1742-48.
34. Tada M, Kuzuya T, Inoue M, et al. Elevation of throm boxane B2 levels in patients with classic and variant angina pectoris. Circulation 1981;64:1107.
35. Goto K, Yasue H, Okumura K, et al. Magnesium deficiency detected by intravenous loading test in variant angina pectoris. Am J Cardiol 1990;65:709-712.
36. Miwa K, Miyagi Y, Igawa A, et al. Vitamin E deficiency in variant angina. Circulation 1996;94:14-8.
37. Miwa K, Igawa A, Nakagawa Ket, al. Consumption of vitamin E in coronary circulation in patients with variant angina. Cardiovasc Res 1999;41:291-8.
38. Motoyama T, Kawano H, Kugiyama K, et al. Vitamin E administration improves impairment of endothelium dependent vasodilation in patients with coronary spastic angina. J Am Coll Cardiol 1998;32:1672-79.
39. Sueda S, Suzuki J, Watanabe K, et al. Comparative results of coronary intervention in patients with variant angina versus those with non-variant angina. Jpn Heart J 2001;42:657-7.
40. Ono T, Ohashi T, Asakura T, et al. Internal mammary revascularization in patients with variant angina and normal coronary arteries. Interact Cardiovasc Thorac Surg 2005;4:426-8.
41. Al-Sayegh A, Shukkur AM, Akbar M. Automatic implantable cardioverter defibrillator for the treatment of ventricular fibrillation following coronary artery spasm: a case report. Angiology 2007;58:122-5.