Prinzmetal angina: An unrecognized cause of recurrent ST elevation myocardial infarction

Background: Prinzmetal's angina is characterized by a transient reduction in luminal diameter of a coronary artery resulting in spontaneous and often recurrent episodes of angina with electrocardiography (ECG) findings consistent with ST elevation. Case report: A 67-year-old male presented with complaint of intermittent chest discomfort during the previous 2-3 weeks. ECG obtained at presentation was consistent with ST elevation in inferior leads. The patient underwent urgent cardiac catheterization with uncomplicated balloon angioplasty to proximal and distal right coronary artery (RCA). At two-week follow up, the patient continued to complain of recurrent chest discomfort with repeat ECG showing ST elevation in inferior leads. He was given nitroglycerin with symptomatic improvement and gradual resolution of ST elevation. Given concern for reocclusion, the patient again underwent urgent cardiac catheterization showing subtotal occlusion of the proximal RCA. During the procedure, intracoronary nitroglycerin was administered with visible resolution of the occlusion via angiography consistent with coronary vasospasm. The patient was therefore initiated on therapy with amlodipine and isosorbide mononitrate and remained symptom free at subsequent follow-up visits. Conclusion: Prinzmetal's angina is a well-documented but under-recognized etiology of recurrent ST elevation myocardial infarction which should be considered in those with both typical and atypical cardiovascular risk profiles.