Rationale: Coronary artery spasm is common ischemic heart disease. It is a serious clinical cardiovascular issue. Nitrates such as nitroglycerine have a pivotal role in the management of coronary artery disease. Patient concerns: A 45-year-old married, officer, heavy smoker, Egyptian male patient presented with acute excruciating severe chest pain and combined electrocardiographic ST-segment coronary artery spasms. Diagnosis: Combined ST-segment coronary artery spasms of ST-segment elevations and ST-depressions were the most probable diagnosis. Interventions: Electrocardiogram, echocardiography, and nitroglycerine intravenous infusion. Outcomes: Dramatic response of both clinical and electrocardiographic combined ST-segment coronary artery spasms to nitroglycerine. Lessons: A combined ST-segment coronary artery spasms including ST-segment elevation and ST-depression may be present in the same ECG. The dramatic efficacy of later using nitroglycerine in the management of combined ST-segment coronary artery spasms.

1. Nitroglycerine-Responsive Combined ST-Segment Coronary Artery Spasms of
High Lateral, Inferior, and Septal Affection; An Extremely Rare Presentation
A case report
Dr. Yasser Mohammed Hassanain Elsayed
2nd World Congress on Congestive Heart Failure & Angina
July 21-22, 2022
Amsterdam, Netherlands

2. Nitroglycerine-Responsive Combined ST-Segment
Coronary Artery Spasms of High Lateral, Inferior, and
Septal Affection; An Extremely Rare Presentation
A case report
Dr. Yasser Mohammed Hassanain Elsayed
Researcher and author
Critical Care Medicine
Egyptian Ministry of Health (MOH)
MB Bch, PGDip Cardiology (Middlesex University, RILA)

4. Learning objectives
• The starting point
• The abstract
• Vocabulary for the current case
• Discovery history
• Identification of keys of the case
• Case presentation

6. . The researcher will be lucky if the case
report will be including deviation from the
straight line.
. Sometimes, the case report takes multiple
ways in understanding.
. The physician should be a strong observer of
the new clinical findings.

8. Rationale: Coronary artery spasm is common ischemic heart disease. It is a serious
clinical cardiovascular issue. Nitrates such as nitroglycerine have a pivotal role in
the management of coronary artery disease.
Patient concerns: A 45-year-old married, officer, heavy smoker, Egyptian male
patient presented with acute excruciating severe chest pain and combined
electrocardiographic ST-segment coronary artery spasms.
Diagnosis: Combined ST-segment coronary artery spasms of ST-segment elevations
and ST-depressions were the most probable diagnosis.
Interventions: Electrocardiogram, echocardiography, and nitroglycerine
intravenous infusion.
Outcomes: Dramatic response of both clinical and electrocardiographic combined
ST-segment coronary artery spasms to nitroglycerine.
Lessons: A combined ST-segment coronary artery spasms including ST-segment
elevation and ST-depression may be present in the same ECG. The dramatic
efficacy of later using nitroglycerine in the management of combined ST-segment
coronary artery spasms.

10. . Combined ST-segment coronary artery
spasms
. Nitroglycerine

12. . Heavy-smoker Egyptian male.
. Resting anginal chest pain.
. ECG and combined ST-segment
elevation and depression.

14. 1. Combined ST-segment coronary artery spasms

15. • Coronary arteries spasm (CAS) is a cardiovascular entity
characterized by chest pain at rest with temporary ECG
ischemic ST-segment changes with a prompt response to
nitrates.
• The term of CAS refers to sudden, intense vasoconstriction
of an epicardial coronary artery that causes vessel occlusion
or near occlusion
• CAS plays a pivotal role in the pathogenesis of ischemic
heart disease, including stable angina, unstable angina,
myocardial infarction, and sudden cardiac death.

16. • The pathophysiology of CAS;
It is interaction of 2 components: (1) It is a usually localized, but
sometimes diffuse, abnormality of a coronary artery that makes it
hyperreactive to vasoconstrictor (VC) stimuli, and (2) There is a VC
stimulus able to induce the CAS at the level of the hyperreactive
coronary segment.
• Transient ST-segment elevation on electrocardiography (ECG) is a
characteristic finding in patients with variant angina
• Coronary angiography may reveal focal CAS when coupled with
typical symptoms, ECG changes, and ventricular dysfunction. It may
also occur in angiographically normal CA as the so-called 'variant of
the variant.

17. • Most CAS is accompanying with ST-segment depression rather
than ST-segment elevation on ECG.

18. 2. Nitrates and Nitroglycerin

19. • Nitrates are the mainstays of medical therapy for vasospastic
angina.
• The use of long-acting nitrates is also effective in preventing
vasospastic events.
• CAS is yielding a dramatic response to the vasodilator action of
nitrates.
• Episodes are usually shortly and quickly alleviated by the
administration of nitrates.
• The ECG abnormalities are temporary and reversible with nitrates.
• However, nitrates causing vasodilation with dominant venous
effects on large capacitance vessels.

20. • They also increase coronary collateral circulation, increase aortic
compliance, and blood flow to ischemic areas of the myocardium.
• In addition, nitrates mitigate anginal symptoms by direct impact on
the CA, coronary collateral circulation, aortic compliance and
conductance, and blood flow to ischemic areas of the myocardium.

21. Case presentation

22. 1. Complaint and History

23. • A 45-year-old married, painter, heavy smoker, Egyptian
male patient presented with acute severe chest pain. Chest
pain was anginal, unbearable, and at rest.
• The anxiety was the only associated symptom.
• The patient is a smoker for about 60 cigarettes per day for
nearly 17 years.
• He denied the history of cardiovascular diseases, the same
attack, drugs, or any other special habits.

24. 2. Physical examination

25. • Generally; the patient was an anxious, severe sweaty, and
had cold extremities.
• Vital signs; a regular heart rate of 78 bpm, BP of 140/100
mmHg, RR of 20 bpm, the temperature of 36.4 °C, and pulse
oximeter of O2 saturation of 98%
• No more relevant clinical data were noted during the
clinical examination.

26. 3. Workup
Serial ECG

27. Figure 1: An initial Emergency ECG tracing showing mild high lateral ST-segment elevation in (I
and aVL) leads (red arrows) and inferior ST-depression depressions in (III and aVF) leads (green
arrows), with NSR of VR;82.

28. Figure 2: Serial ECG tracings in ICU A. tracing showing high lateral ST-segment elevation in (I and aVL) leads (red
arrows) and inferior ST-depressions in (III and aVF) leads (green arrows), and septal ST-depression depressions in (III and
aVF) leads (blue arrows) with NSR of VR;78. B and C tracings showing gradual resolution of the above ST-elevations and
ST-depressions with a gradual decrease in the number of affected leads.

29. Figure 3: ECG tracing showing complete electrocardiographic ST-segment normalization of the above elevations and ST-
depressions with NSR of VR;70.

30. B. Troponin test
• The serial troponin test was negative (less than 0.001 ng/L)
C. RBS
• Measured random blood sugar was 171 mg/dl.

31. D. Echocardiography
• Later echocardiography showed mild diastolic
dysfunction with EF 65%.

32. E. No more workup
• No more workup was done.

33. The most probable diagnosis
• Combined ST-segment coronary artery spasms
of ST-segment elevation and ST-depression.

35. • Patient was admitted to ICU as as anginal chest pain and hypertension.
• The initial ECG tracing was taken in the EDmild high lateral ST-segment elevation in (I
and aVL) leads and inferior ST-depression depressions in (III and aVF) leads, with NSR
(Figure 1).
• He was initially managed with O2 inhalation using nasal cannula in rate of 5
L/min.
• Pethidine HCL 100 mg given on intermittent IV doses.
• Aspirin 4 chewable oral tablet (75 mg).
• Clopidogrel 4 oral tablet (75 mg).
• Bisoprolol 1 oral tablet (5 mg).

36. • Enoxaparin SC injection (60 mg twice daily) was added.
• Unfortunately; still there was no clinical or ECG improvement.
• Serial ECG tracings in ICU showing high lateral ST-segment elevation in (I
and aVL) leads and inferior ST-depressions in (III and aVF) leads, and septal
ST-depression depressions in (III and aVF) leads with NSR of VR;78 (Figure
2 A).
• Intravenous nitroglycerin infusion (7.5 µg/min with intermittent titration)
was added. Blood pressure became normalized (130/70. mmHg).

37. • Gradual resolution of the above ST-elevations and ST-depressions with a gradual
decrease in the number of affected leads. (Figure 2 B-C).
• The patient was continued on diltiazem tablet (60 mg twice daily), and
nitroglycerin retard capsule (2.5 mg twice daily) until discharged on the 2nd day.
• He continued on diltiazem tablet (60 mg twice daily), and nitroglycerin retard
capsule (2.5 mg twice daily).
• Planning for catheter revascularization was a future option.

39. • Overview: A 45-year-old heavy smoker male patient presented with anginal
severe chest pain at rest. An electrocardiographic combined ST-segment
coronary artery spasms including ST-segment elevation and ST-depression
was the hallmark of the current case.
• The primary objective; for my case study was the presence of anginal severe
chest pain at rest and combined ST-segment coronary artery spasms in ECG.
Smoking was a major risk factor.

40. • Study question here; How did combined ST-segment coronary artery
spasms with ST-segment elevation and ST-depression in the same ECG?
• The secondary objective; for my case study was the initial resistance of the
case to standard anginal treatment.
• The dramatic efficacy on later using nitroglycerine in the management of
combined ST-segment coronary artery spasms.

41. • The author thinks that the unbearable anginal pain may correlate
specifically to lateral coronary artery spasms.
• The acute high lateral ST-segment elevation myocardial infarction (STEMI)
is the main differential diagnosis.

42. Acknowledgment
I wish to thank Ahmed Alghobary,
B.sc. for his technical support.

44. • A combined ST-segment coronary artery spasms
including ST-segment elevation and ST-depression may
be present the same ECG.
• Also, it is recommended to extend the research on the
impact of nitroglycerine in the management of both
clinical and electrocardiographic combined ST-
segment coronary artery spasms.

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