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In 1959 Myron Prinzmetal first described variant angina. Without the aid of selective coronary angiography he attributed the syndrome to the “temporary occlusion of a large diseased artery with a narrow lumen due to a normal increase in the tonus of the vessel wall.”
A 66 year old woman who had been smoking 15 cigarettes each day for 50 years and who had a long history of Raynaud’s syndrome presented with an episode of severe chest pain associated with pronounced ST elevation in the inferior and lateral leads (left). She was enrolled in a thrombolytic trial that involved the performance of early coronary angiography. Ninety minutes after receiving 100 mg of tissue plasminogen activator the ST segments were still elevated. Coronary angiography of the right coronary artery showed a discrete 90% stenosis that resolved following 200 μg of intracoronary nitroglycerin (top). An ECG recorded 30 minutes later demonstrated complete resolution of the ST segments (bottom). There was no subsequent enzyme rise.
The patient continued to have frequent episodes of chest pain lasting 10–15 minutes associated with similar ST elevation. The symptoms continued despite high doses of long acting nitrates and nifedipine, cessation of smoking, and withdrawal of metoprolol. She had no further attacks following the addition of nicorandil.