A 61 year old woman undergoing nasal polypectomy developed hypotension and ST elevation in the inferior leads on ECG. She was previously well with no risk factors for ischaemic heart disease. Troponin I was raised at 3.5 ng/ml. Coronary angiography revealed a normal left system with diffuse spasm of the right coronary artery (panel A). This resolved completely with the administration of intracoronary glyceryl trinitrate (panel B).

The nasal pack inserted at the time of nasal polypectomy contained Brompton’s solution (cocaine hydrochloride 15 g (3%), adrenaline (epinephrine) (1 in 1000) 125 ml, potassium sulphate 2.5 g, and phenol 1.2 g in 500 ml purified water). Urinary cocaine metabolites subsequently tested positively. The patient’s symptoms settled on removal of the pack and she made an uneventful recovery.