• Images in cardiology

A 73 year old man presented with anginal chest pain and dyspnoea at rest in the morning. Echocardiography showed moderate mitral regurgitation and normal left ventricular wall motion. Coronary angiography revealed spontaneous tandem vasospasm, which looked like beads, in the first diagonal branch of the left anterior descending artery, but no significant spastic or organic stenosis in other segments (panel A). An intracoronary injection of 0.5 mg glyceryl trinitrate quickly relieved this bead-like vasospasm (panel B). An acetylcholine provocation test was carried out seven days later. All coronary vasodilating drugs were discontinued more than 24 hours before the examination. Repeated coronary angiography revealed no significant vasospasm in any coronary artery. Intracoronary injection of 50 μg acetylcholine into the left coronary artery caused diffuse and severe vasospasm in many segments, but could not reproduce the bead-like vasospasm (panel C). Again, an intracoronary injection of glyceryl trinitrate quickly relieved the vasospasm (panel D).

To the best of our knowledge, this is the first published report of a patient with bead-like vasospasm, and it suggests that the acetylcholine provocation test does not always reproduce the clinical vasospasm. How this mysterious form of vasospasm occurs remains unknown.