Eman Hassan
Sheikh Shakhbout Medical City, United Arab Emirates
Title: Coronary Vasospasm in a Patient with Minoca
Biography
She is an experienced physician with over 13 years of clinical practice, specializing in internal medicine and cardiology. She possesses in-depth knowledge of medical policies, procedures, and evidence-based treatment protocols, with a strong commitment to delivering exemplary patient care. She holds board certification in Internal Medicine from the Arab Board and is a Member of the Royal College of Physicians of London. Additionally, she is a certified general cardiologist, having completed a comprehensive and structured training program accredited by the Arab Board for Health Specializations, ACGME-International, the Jordanian Board, and the Emirati Board.
Abstract
Background
- Around 5-6% of acute myocardial infarctions (AMIs) occur in the absence of obstructive coronary artery disease, a condition known as MINOCA (myocardial infarction with non-obstructive coronary arteries) (1).
- Coronary vasospasm is common among the potential causes of MINOCA, accounting for 46% of cases (2). However, diagnosing coronary artery vasospasm (CAVS) can be challenging; often patients are labelled, rightly or wrongly, with this diagnosis when symptoms persist in the absence of documented obstructed coronary artery disease.
- However, CAVS can be diagnosed definitively with provocative testing when carried out at the same time as coronary angiography (3).
Case Presentation:
We present the case of a 63-year-old woman with a history of diabetes mellitus and recurrent chest pain who was diagnosed with MINOCA following “normal” coronary angiography in November 2022 when she presented with an NSTEMI. She presented again in 2023 with similar coronary ischaemic symptoms. Initial ECG was unremarkable; however, transient ST elevation was noted in the inferior leads during episodes of chest pain. Echocardiography excluded regional wall motion abnormalities and serial high sensitivity troponin levels were below the URL (14 ng/L) apart from one reading of 15.8 ng/L. In view of her presentation and dynamic ECG, she underwent a coronary angiography, which revealed mild (<50%) mild-vessel disease of the left anterior descending artery (LAD) with muscle bridging. No significant disease was noted in the right coronary artery (RCA) or the left circumflex artery (LCx).
Fractional flow reserve (FFR) testing of the LAD was negative. The patient underwent further coronary physiology testing with a normal coronary flow reserve of 3.0 (normal >2.50) and normal index of myocardial resistance of 6 (normal <25), thus excluding coronary microcirculatory dysfunction. She proceeded with an acetylcholine provocation test, which confirmed the diagnosis of coronary vasospastic angina with severe (almost complete epicardial arterial occlusion) arterial spasm in the LAD and LCx associated with typical chest pain, ST depression and hypotension, showing severe spasms of the coronaries that led to hypotension and typical chest pain with ECG changes.
Discussion:
The diagnosis of vasospastic angina can be made easily and safely in the Cardiac Catheterisation Laboratory using incremental doses of intracoronary acetylcholine. Diagnosis requires evidence of >90% coronary arterial spasm + typical symptoms + ECG evidence of ischaemia.
Patients with MINOCA and suspected coronary vasospasm should receive calcium channel blockers as the first-line therapy. However, if coronary atherosclerosis is present, other medications such as nitrates and potassium channel activators may be considered in addition to ACE/ARB and statin therapy. Risk stratification for patients with MINOCA and unclear etiology remains a challenge. This case highlights the importance of considering coronary vasospasm as a possible cause of MINOCA and using invasive coronary imaging and physiology testing to evaluate such patients.
Intracoronary nitroglycerin and atropine were required to reverse the coronary spasm and relieve her symptoms.
References:
https://pubmed.ncbi.nlm.nih.gov/30913893/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8897020/
http://www.ncbi.nlm.nih.gov/books/NBK470181
17-18 Nov 2025 
Dubai, UAE (Collaboration with the Armenian Cardiologists Association) 
