P106 an intriguing case of inoca in the cath–lab

Abstract A 63–year–old woman presented to our Center for a longstanding history of typically radiating oppressive chest pain, with both resting and exertional episodes,mostly occurring early in the morning and exacerbated by cold.Two years before for a treadmill test positive for electrocardiographic (EKG) criteria of exercise–induced ischemia, she underwent coronary angiography which was found negative for epicardial obstructive coronary artery disease.Given the suspicion of coronary microvascular disease,empirical antianginal therapy with Ranolazine was started at that time,with transient improvement of symptoms. She presented to our Center for a 6 month history of recurrence of symptoms. Her antianginal therapy with Ranolazine was up titrated to 750 mg BID and Verapamil (40 mg TID) was added to her usual therapy given the suspicion of coronary vasospasm as additional component in the pathogenesis of her symptoms,as suggested by the anamnestic recall.Moreover a 24–hour–Holter monitoring was performed with subsequent finding of several episodes of horizontal ST–segment depression(up to 3 mm),mainly on awakening,in the absence of significant arrhythmias.The patient underwent coronary angiography for the assessment of coronary physiology. On angiography, the absence of epicardial obstructive coronary artery disease was confirmed, with the finding of extensive coronary fistulas originating from the left coronary system and communicating with the left ventricular cavity.After induction of maximal hyperemia, the clinical suspicion of coronary microvascular disease was confirmed (CFR 1.9).In addition, reduced coronary flow reserve in the left anterior descending (LAD) territory compatible with both microvascular dysfunction and coronary steal was documented (RFR 0.91;baseline FFR:0.94,after systemic adenosine:0.79).Given the clinical suspicion, vasoreactivity test with intracoronary acetylcholine (2–20–100–200 mcg) was also performed,which was positive for epicardial spasm at mid–distal LAD and concomitant onset of chest pain and ischemic EKG changes(diffuse ST–segment depression) with prompt regression after intracoronary nitrate administration.Taken together,clinical and instrumental findings suggested the diagnosis of mixed angina by combination of three mechanisms:microvascular disease,epicardial spasm and coronary steal due to extensive coronary artery fistulas.The patient was discharged with Ranolazine and Diltiazem at maximum tolerated dose with clinical benefit.