PMC9877510_01
Coronary angiogram 3 months ago, when inferior wall MI occurred. (A, B) mild coronary artery narrowings in both LCx and LAD (white arrows); (C) severe narrowings in the RCA (white arrows); (D) RCA after stents implantation (red arrows indicate both implanted stents) (LAD, left anterior descending artery; LCx, left circumflex artery; MI, myocardial infarction; RCA, right coronary artery).
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F1
Three months ago he was admitted to a different percutaneous coronary intervention (PCI) center due to inferior wall STEMI and two drug-eluting stents were implanted: one in the proximal part of the RCA, the other in the right posterolateral (rPL) branch (Figure 1). PCI center a repeat coronary angiogram was performed due to a suspicion of unstable angina but no visual stenoses were identified, coronary artery flow was not impaired (Figure 2, Table 1). Patient was advised to continue dual antiplatelet therapy and atorvastatin.
Coronary angiogram when recurrent chest pain episodes occurred after PCI. Both left and right coronary arteries are patent, their filling is unimpaired. No narrowings in the mid RCA, LAD and LCx, which were observed during the initial coronary angiogram, are present. White arrows indicate stents implanted in the RCA (LAD, left anterior descending artery; LCx, left circumflex artery; RCA, right coronary artery).
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F2
PCI center a repeat coronary angiogram was performed due to a suspicion of unstable angina but no visual stenoses were identified, coronary artery flow was not impaired (Figure 2, Table 1). Patient was advised to continue dual antiplatelet therapy and atorvastatin.
ECG recorded on admission demonstrating ST-segment elevation in leads II, III, aVF with reciprocal ST-segment depression in leads I and aVL (ECG, electrocardiogram).
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F3
During the current hospital admission, an initial electrocardiogram (ECG) showed ST-segment elevation in leads II, III and aVF with reciprocal ST-segment depression in leads I and aVL (Figure 3).
Coronary angiogram from the current stay. (A) severe diffuse RCA spasm (indicated by the white arrows), previously implanted stents (red arrows); (B) improved RCA spasm after intracoronary injection of 300 mcg nitroglycerine; (C) further resolution of vasospasm after administering additional 100 mcg nitroglycerine and 2.5 mg verapamil; (D, E) visible vasospasms in both LCx and LAD; (F) vasospasm resolution after 100 mcg nitroglycerine and 2,5 mg verapamil intracoronarily (LAD, left anterior descending artery; LCx, left circumflex artery; RCA, right coronary artery).
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F4
It revealed a diffuse severe narrowing of the right coronary artery (RCA) and mild to moderate stenoses in both left anterior descending (LAD) and left circumflex (LCx) arteries (Figure 4).
(A) Post-procedural ECG from ICU showing resolution of ST-segment elevation in leads II, III and aVF with formation of negative "reperfusion" T waves in III and aVF leads. (B) ECG during the night chest pain episode showing no significant changes compared with (A) (ECG, electrocardiogram, ICU, intense care unit).
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F5
Post-procedural ECG showed the return of ST-segment to the baseline (Figure 5A). The ECG recorded during the pain episode did not reveal any new electrocardiographic signs of myocardial ischemia (Figure 5B).