International Journal of Clinical & Medical Images

Clinical Presentation: A 37-year-old woman, an active smoker and history of migraine headache presented to the emergency department (ED) with sudden onset of pressure like chest pain associated with dizziness and one episode of vomiting. Her symptoms resolved in few minutes after self-administration of sub-lingual nitroglycerin. On arrival to emergency department she was asymptomatic with normal physical examination, electrocardiogram (Figure 1) and chest X-ray. The patient reported having similar symptoms 8 months earlier and admitted in another city hospital where she was diagnosed to have non ST elevation myocardial infarction (NSTEMI). A, cardiac catheterization revealed left anterior descending artery (LAD) fibromuscular dysplasia, however, no stent was placed and the patient was discharged on Aspirin, Clopidogrel, Isosorbide Mononitrate, Metoprolol and Pravastatin. Few hours after arrival to ED she had recurrent chest pain associated with pallor and diaphoresis, repeat electrocardiogram showed an ST segment elevation in lead II, III, AVF and ST segment depression in lead I and AVL (Figure 2). The patient was taken for emergency cardiac catheterization where coronary angiogram revealed severe spasm of right coronary artery (Figure 3) which resolved after administration of intra-coronary nitroglycerin (Figure 4). Cardiac markers repeatedly reported negative and electrocardiogram after coronary angiogram showed resolution of EKG abnormalities (Figure 5). Diagnosis of prinzmetal’s angina (Variant Angina) was made. The patient was discharged home on long acting nitrate, calcium channel blocker and advised on smoking cessation.

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