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  • Title: [Unstable angina pectoris--combination of an epicardial stenosis and a Prinzmetal spasm].
    Author: Bentz K, Ong P, Sechtem U.
    Journal: Dtsch Med Wochenschr; 2013 Dec; 138(49):2546-9. PubMed ID: 24281968.
    Abstract:
    HISTORY AND ADMISSION FINDINGS: A 61-year-old man presented with recurrent angina pectoris at rest for 3 days. The medical history revealed hypertension and an elevated cholesterol level as cardiovascular risk factors. INVESTIGATIONS: The physical examination revealed no pathological findings. ECG at admission showed no signs of ischemia, while high-sensitive Troponin T was slightly elevated. Echocardiography showed diastolic dysfunction and biatrial dilatation. TREATMENT AND COURSE: During another episode of angina at rest, ECG showed T-wave inversion in lead aVL. Therefore, coronary angiography was performed. At the beginning of the examination the patient complained of angina at rest and ECG showed ST-elevation in the inferior leads. Coronary angiography revealed a subtotal stenosis in the middle part of the RCA. After intracoronary nitroglycerin injection there was a high-grade stenosis in this region. An intracoronary acetycholin provocation test was performed which reproduced a focal spasm in the area of the RCA stenosis with simultaneous changes in the ECG and reproduction of the patient's unusual angina. After implantation of a bare metal stent a subsequent ACH-test did not elicit any further coronary spasm. Four weeks after the procedure the patient had no further complaints under medical treatment. CONCLUSION: This case illustrates a patient with a focal Prinzmetal-type spasm with ST-elevation on top of a high-grade stenosis of the right coronary artery as an explanation for the unstable angina. Coronary spasm of the Prinzmetal-type can occur in vessels with epicardial stenosis as well as in vessels without stenosis. In some cases focal coronary spasm can be prevented by the implantation of a stent.
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