Abstract
We present 2 illustrative cases of acute coronary syndrome and spontaneous coronary artery spasm evaluated by optical coherence tomography. Different spasm patterns were showed by optical coherence tomography (OCT), according to whether there were underlying atherosclerotic plaques or not.
Highlights
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Optical coherence tomography images revealed an intima and mid layer thickening during the spasm with a typical appearance of humps.
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Optical coherence tomography can rule out the existence of other intracoronary underlying pathology like plaque erosion, thrombi or dissection.
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We can recognize different patterns of spasm by optical coherence tomography depending on the underlying substrate and/or the severity of spasm.
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A 62 years-old female, smoker was admitted to the coronary care unit with non-ST elevation myocardial infarction (NSTEMI). The clinical examination was unremarkable. Initial ECG shows Q wave in the anteroseptal leads (V1–3). Cardiac troponin was elevated (324). Regional wall motion abnormalities were seen in the form of hypo-kinetic basal septal and inferolateral walls with preserved ejection fraction. Coronary angiography was performed by radial approach and revealed mild proximal LAD atheroma with suspected spasm ( Fig. 1 A ).
Fig. 1
A: Angiogram showing a spontaneous left anterior descending artery mild proximal atheroma with suspected spasm (black arrow). B: Angiogram showing the left anterior descending artery after nitrates with mild proximal atheroma at the spot of the spasm. C: Optical coherence tomography cross section image showing spastic left anterior descending artery. The lumen is severely narrowed with thickened intima and media. The image shows intimate gathering and protruding humps at 8 o’clock. D: Longitudinal optical coherence tomography image during the spasm (white arrow). E: Mild lipidic atheroma appears after relief of the spasm.
At that point, we decided to evaluate this spot with an optical coherence tomography (OCT). Optical coherence tomography revealed a spontaneous coronary spasm at the site of the angiographic atheroma. The vessel appearance showed a significant increase in artery media thickness with narrowed lumen and decreased diameter, compared with the adjacent artery. The intima layer appeared enlarged and with the typical appearance of humps on its surface ( Fig. 1 C and D).
After giving intracoronary nitroglycerin the coronary spasm was relieved showing underlying intermediate coronary plaque ( Fig. 1 B). The plaque was lipidic with signal poor areas having a diffuse border due to back scattering effect and covered by a homogenous signal rich fibrous cap ( Fig. 1 E). We did not notice any luminal irregularities, thrombi or plaque disruption.
Conservative management was adopted without stenting. The patient was prescribed calcium channel blocker together with anti-platelets without recurring of any symptoms at 9 month follow up.
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A 51 years-old male smoker, hypertensive and hyperlipidemic with prior history of spontaneous coronary artery dissection treated with percutaneous coronary intervention (PCI) on mid LAD 5 years ago. He was admitted with NSTEMI. The coronary angiogram revealed a focal angiographic lesion on posterolateral branch and a diffuse narrowing of circumflex artery from mid to apical segment due to intramural hematoma (type 2 SCAD). Optical coherence tomography was performed confirming these suspicions on the circumflex artery, and showing a spontaneous coronary focal spasm on the posterolateral branch. The vessel appearance showed a significant increase in intima and media layer thickness but in this case without the typical humps appearance described before ( Fig. 2 ).
