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A 49 year old woman with history of angina at rest and syncope was admitted for evaluation. During hospitalisation the patient was resuscitated following a cardiac arrest. Left cardiac catheterisation revealed coronary arteries without significant stenoses. Upright tilt testing and electrophysiological study were negative. Two weeks after discharge a symptomatic out-of-hospital ventricular tachycardia was recorded. The patient repeatedly experienced paroxysmal episodes of typical angina lasting up to 15 minutes. At rehospitalisation continuous telemetric electrocardiographic monitoring documented ST segment elevations (panel A) with premature ventricular contractions and short runs of torsades de pointes ventricular tachycardia (panel B). A spontaneous normalisation of ST segments with transient ST segment depression was observed 12 minutes after the symptoms and ECG changes had begun (panel B). Repeat coronary angiography on the following day showed spontaneous coronary artery spasms in multiple arteries (solid arrows in panels C and E) with transient occlusion of the first obtuse marginal branch of the left circumflex artery (open arrows in panel F). After intracoronary administration of glyceryl trinitrate there was normalisation of the coronary artery diameters (panels D and F) and ECG abnormalities.
The findings confirm that life threatening ventricular arrhythmia may occur in Prinzmetal’s variant angina. Subsequently, the patient was treated with slow release molsidomine 16 mg, slow release isosorbide dinitrate 120 mg, and nifidipine 60 mg daily. During a follow up period of nine months, the patient was free of symptoms.