Pre-infarction Prinzmetal's angina. A case report and review of the literature.

A 45-year-old White man presented with the classic history of Prinzmetal's variant angina, culminating in a transmural inferior myocardial infarction despite intensive treatment with continuous nitroglycerin infusion and the oral calcium antagonist nifedipine. During the frequent episodes of 'pre-infarction' Prinzmetal's variant angina intermittent second-degree atrioventricular heart block as well as ventricular tachycardia was witnessed, necessitating the insertion of a temporary transvenous right ventricular pacemaker. Selective coronary angiography performed approximately 1 week after the infarction in an attempt to elucidate the cause of continuing chest pain unresponsive to medication showed subtotal occlusion of the distal part of the dominant right coronary artery proximal to the origin of the artery to the atrioventricular node, while only very minor narrowings of the internal lumen were evident in the left coronary artery. The well-known angiographic features of a resolving intracoronary thrombus were visualized without any superimposed reversible coronary vasospasm. After catheterization the angina settled down and the patient was discharged on oral nifedipine and isosorbide dinitrate treatment. The place of coronary artery spasm in the pathophysiology of acute myocardial infarction, one facet of the clinical spectrum of ischaemic heart disease, is reviewed.