Case Presentation: A 22-year-old African-American man with no medical history presented to the emergency department after an episode of sudden onset palpitations and left sided chest pressure lasting an hour. He endorsed radiation of his discomfort to his jaw and left arm as well as accompanying diaphoresis, shortness of breath and pre-syncope. Physical examination was normal. Laboratory evaluation was notable only for a urine toxicology screening positive for cannabinoids. Electrocardiogram showed normal sinus rhythm with deep Q waves in the inferior and lateral leads. Chest radiography was normal. Echocardiogram revealed an aneurysmal left ventricular apex, apical akinetic segments and an ejection fraction between 45 and 50 percent. Cardiac magnetic resonance imaging was pursued given depressed ejection fraction and wall motion abnormalities in a young patient. It revealed a moderately dilated left ventricle with an aneurysmal apex that moved paradoxically. The apical myocardium exhibited delayed gadolinium enhancement suggesting a vascular etiology, specifically infarction of the left anterior descending artery. As a result, left heart catheterization was performed and showed normal coronary arteries. Given these findings, a diagnosis of coronary artery vasospasm causing left ventricular apex myocardial infarction was made.
Due to the patient’s myocardial dysfunction in the setting of a left ventricle apical scar, there was concern that his palpitations, chest pressure and pre-syncope may have been secondary to ventricular tachycardia. Telemetry monitoring did not reveal any arrhythmias, however, because of significant concern for ventricular tachycardia, an electrophysiology study was performed and was negative for inducible ventricular tachycardia. Patient was discharged on medical management including amlodipine for vasospasm, lisinopril and metoprolol succinate for cardiomyopathy, and a wearable defibrillator. Close follow up was arranged to re-assess myocardial function and further discussion of implantable defibrillator.
Discussion: This case serves as an example of vasospastic angina causing myocardial dysfunction in a young adult. It also highlights the need to consider vasospastic angina as the etiology of a patient’s chest discomfort particularly in those of young age and without traditional cardiac risk factors. As in this case, it is imperative that clinicians consider a broad differential diagnosis in all patients presenting with chest pain in order to reach an accurate diagnosis and pursue appropriate treatment.
Conclusions: Vasospastic angina is a well-described entity of myocardial ischemia that occurs in the absence of atherosclerotic lesions and typical risk factors associated with coronary artery disease. Unfortunately, clinicians may overlook this clinical entity as the etiology of chest pain, particularly in young adults who are deemed to have a low pre-test probability with respect to a myocardial or vascular etiology of chest discomfort. This case shows why it is important to include vasospastic angina in all cases of young adults with chest pain because of the possible morbidity associated with it.