Spontaneous ST Elevation Caused by Coronary Vasospasm: Exercise Testing and Ambulatory ECG
Journal of the American College of Cardiology
Background: Definitive diagnosis of coronary vasospasm is difficult given the transience of symptoms. We present a case where exercise testing and ambulatory ECG was used to confirm diagnosis and monitor therapy. Case: A 53-year-old male presents with one-month of chest tightness occurring at rest and with high-intensity exercise. ACS was ruled-in with a Troponin I level of 0.21 ng/mL. An invasive coronary angiography revealed a proximal LAD lesion causing 50% stenosis with an invasive FFR value of 0.85. NIRS-IVUS revealed fibrous plaque with no lipid core. CMR showed anterior wall myocardial edema without late gadolinium enhancement. Inpatient telemetry uncovered frequent episodes of fleeting ST elevation (STE) and NSVT. An exercise stress test revealed dynamic STE occurring throughout exercise. He was treated with amlodipine and isosorbide mononitrate. Repeat in-hospital exercise testing revealed no dynamic STE and telemetry had no further abnormalities. Decision-making: Given the dynamic STE suggesting myocardial ischemia, aggressive inpatient titration of medications and follow up exercise testing was pursued. Given his desire to return to high-intensity exercise, an implantable loop recorder was placed to monitor for STE. On outpatient follow-up, he had complete cessation of symptoms and STE. Conclusion: This case illustrates the dynamic nature of coronary vasospasm and the use of exercise testing and ambulatory ECG to confirm the diagnosis and monitor therapy.
Vira A, Mehta N, Safian RD. Spontaneous ST elevation caused by coronary vasospasm: exercise testing and ambulatory ECG. J Am Coll Cardiol. 2022 Mar 8;79(9 Suppl):2958.