International Journal of Vascular Medicine

International Journal of Vascular Medicine / 2010 / Article

Case Report | Open Access

Volume 2010 |Article ID 207479 |

Damian Franzen, Thomas Benzing, "Exercised-Induced Coronary Spasm in Near Normal Coronary Arteries", International Journal of Vascular Medicine, vol. 2010, Article ID 207479, 4 pages, 2010.

Exercised-Induced Coronary Spasm in Near Normal Coronary Arteries

Academic Editor: John A. Kern
Received23 Feb 2010
Accepted10 May 2010
Published17 Jun 2010


In contrast to effort-induced symptoms in obstructive coronary disease, spasm in normal coronary arteries is characterized by angina at rest. We describe a 44-year-old patient with minor coronary plaques and pure exercised-induced coronary spasm. The case questions the differential pathogenic considerations of variant of the variant as opposed to Prinzmetal's variant angina.

1. Introduction

As outlined by Maseri and coworkers, coronary artery spasm is a potential cause of angina pectoris in patients with and without atherosclerotic coronary heart disease [1]. Whereas spasm in obstructive coronary artery disease (termed variant angina) may be quite common, angina in (near) normal coronary arteries (called the variant of the variant angina) is rare and likely to be misdiagnosed [2]. Although the clinical picture in variant of the variant angina may vary considerably, anginal symptoms occur spontaneously and typically at rest. Symptoms may be accompanied by ST-depression or occasionally by ST-segment elevation in the electrocardiogram, however exercise tests are usually negative [3]. In the following we report on a case of pure exercise induced coronary spasm in a 44-year-old man.

2. Case Presentation

In June 2008, a 44-year-old salesman started to suffer from chest discomfort during hiking and bicycle riding. However, bicycle stress testing was negative. He was nonsmoker and his LDL-cholesterol was normal (101 mg/dL). Because of recurrent episodes of effort-related thoracic pain alleviated by sublingual nitroglycerine and a family history of coronary heart diseases in both parents, the patient underwent cardiac catheterization in July 2008, demonstrating near normal vessels with minor and nonobstructive sclerotic lesions at the left anterior descending and the right coronary arteries. Because of mild hypertension during exercise, he was treated with ramipril 2,5 mg daily.

As symptoms increased in intensity and frequency, another stress test in January 2009 at our institution revealed exercise induced ST-depression in leads V4–V6 accompanied by typical anginal symptoms (Figure 1). A second cardiac catheterization demonstrated a mild stenosis in the mid portion of the left anterior descending coronary artery (LAD), all other coronary arteries were without visible stenosis (Figures 2 and 3). During the procedure the patient suddenly complained of anginal symptoms accompanied by ST elevation and finally ventricular tachycardia. The LAD was found occluded beginning at the stenotic segment of the mid LAD (Figure 4). All symptoms and the spasm resolved spontaneously (Figure 5).

In the following, acetylcholine was infused into the left coronary artery resulting in complete occlusion of the LAD accompanied by angina and ST-depression (Figure 6) resolving directly to intracoronary nitroglycerine.

The patient was put on long-term medication with isosorbide dinitrate and amlodipine and was free of symptoms thereafter.

3. Discussion

Obstructive atherosclerotic lesions are the leading cause of symptomatic coronary heart disease throughout the Western civilization. As opposed to effort-induced symptoms due to stenotic coronary disease, Prinzmetal reported about a special cohort of patients with angina at rest (variant angina). He speculated on an increased vascular tone at the site of coronary plaques which had been found at postmortem studies [4]. Myocardial ischemia in normal coronary arteries has been initially documented by Cheng and coworkers [2]. Based on the clinical similarities to the variant angina of Prinzmetal, this syndrome has been termed the variant of the variant. Cheng concluded that spasm of normal coronary arteries was the most likely explanation for the observed complete relief of symptoms and coronary dilatation following nitroglycerine application. In clinical settings, spasm can be diagnosed by intracoronary provocation with ergonovine or acethylcholine [3, 5, 6] and should be separated from mechanical induced spasm due to catheter manipulation at the coronary ostia or traumatic intracoronary manipulation during cardiac catherization.

Coronary spasm in normal coronary arteries occurs mostly at rest, in rare cases at rest and during exercise [7, 8]. In the presented patient, anginal symptoms during every day life were provoked by exercise only and accompanied by ST-depression. Although symptoms indicated severe underlying organic vascular obstruction, coronary angiography demonstrated coronary spasm of the left anterior descending coronary artery. It has been speculated that coronary spasm may be related to an abnormal vasoconstrictor stimulus or to a local arterial hypersensitivity to physiologic stimuli [911].

It seems mandatory for the spastic vascular response to a generalized stimulus to be based on an pathologic substrate within a particular segment of the arterial wall. Although numerous articles on spasm in symptomatic patients without angiographic detectable coronary disease have been published, imaging with newer technologies such as intracoronary ultrasound and coronary tomography question whether spasm is an entity on its own (variant of the variant) or always related to the presence of atherosclerosis (Prinzmetal’s variant angina) [12]. The presented case of effort-induced spasm in a mildly diseased coronary artery system seems to support this suggestion.


  1. A. Maseri, S. Severi, M. Denes et al., ““Variant” angina: one aspect of a continuous spectrum of vasospastic myocardial ischemia. Pathogenetic mechanisms, estimated incidence and clinical and coronary arteriographic findings in 138 patients,” The American Journal of Cardiology, vol. 42, no. 6, pp. 1019–1035, 1978. View at: Google Scholar
  2. T. O. Cheng, T. Bashour, G. A. Kelser Jr., L. Weiss, and J. Bacos, “Variant angina of Prinzmetal with normal coronary arteriograms. A variant of the variant,” Circulation, vol. 47, no. 3, pp. 476–485, 1973. View at: Google Scholar
  3. T. O. Cheng, “Ergonovine test for coronary artery spasm,” International Journal of Cardiology, vol. 114, no. 2, pp. 249–250, 2007. View at: Publisher Site | Google Scholar
  4. M. Prinzmetal, R. Kennamer, R. Merliss, T. Wada, and N. Bor, “Angina pectoris I. A variant form of angina pectoris. Preliminary report,” The American Journal of Medicine, vol. 27, no. 3, pp. 375–388, 1959. View at: Google Scholar
  5. I. Coma-Canella, S. Castano, A. Macías, J. Calabuig, and M. Artaiz, “Ergonovine test in angina with normal coronary arteries. Is it worth doing it?” International Journal of Cardiology, vol. 107, no. 2, pp. 200–206, 2006. View at: Publisher Site | Google Scholar
  6. P. Ong, A. Athanasiadis, S. Hill, H. Vogelsberg, M. Voehringer, and U. Sechtem, “Coronary artery spasm as a frequent cause of acute coronary syndrome. The CASPAR (Coronary Artery Spasm in Patients with Acute Coronary Syndrome) study,” Journal of the American College of Cardiology, vol. 52, no. 7, pp. 523–527, 2008. View at: Publisher Site | Google Scholar
  7. G. Specchia, S. de Servi, C. Falcone et al., “Coronary arterial spasm as a cause of exercise-induced ST-segment elevation in patients with variant angina,” Circulation, vol. 59, no. 5, pp. 948–954, 1979. View at: Google Scholar
  8. S. B. Freeman, D. R. Richmond, and D. T. Kelly, “Clinical studies of patients with coronary spasm,” American Journal of Cardiology, vol. 52, no. 2, pp. 67–71, 1983. View at: Google Scholar
  9. H. Yasue, M. Touyama, H. Kato, S. Tanaka, and F. Akiyama, “Prinzmetal's variant form of angina as a manifestation of alpha adrenergic receptor mediated coronary artery spasm: documentation by coronary arteriography,” American Heart Journal, vol. 91, no. 2, pp. 148–155, 1976. View at: Google Scholar
  10. H. Yasue, M. Nagao, S. Omote, A. Takizawa, K. Miwa, and S. Tanaka, “Coronary arterial spasm and Prinzmetal's variant form of angina induced by hyperventilation and tris-buffer infusion,” Circulation, vol. 58, no. 1, pp. 56–62, 1978. View at: Google Scholar
  11. T. T. Bashour, “Vasotonic myocardial ischemia,” American Heart Journal, vol. 122, no. 6, pp. 1701–1722, 1991. View at: Publisher Site | Google Scholar
  12. Y. J. Hoon, M. H. Jeong, Y. H. Choi et al., “Plaque components at coronary sites with focal spasm in patients with variant angina: Virtual histology-intravascular ultrasound analysis,” International Journal of Cardiology, May 16, 2009. In press. View at: Publisher Site | Google Scholar

Copyright © 2010 Damian Franzen and Thomas Benzing. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

More related articles

 PDF Download Citation Citation
 Download other formatsMore
 Order printed copiesOrder

Related articles

We are committed to sharing findings related to COVID-19 as quickly as possible. We will be providing unlimited waivers of publication charges for accepted research articles as well as case reports and case series related to COVID-19. Review articles are excluded from this waiver policy. Sign up here as a reviewer to help fast-track new submissions.