Prevention of epicardial coronary artery spasm with intracoronary nitroglycerine during acetylcholine testing in a female patient with resting angina—implications for optimal pharmacological management

We here present the case of a 55‐year old woman who presented with recurrent angina at rest followed by presyncopal attacks and nausea to our clinic. Her only cardiovascular risk factor was arterial hypertension. High‐sensitive troponin T was 3 pg/ml (n < 14 pg/ml) and the 12‐lead resting ECG was unremarkable. Differential diagnoses included stenosing coronary artery disease and coronary artery spasm. Thus, invasive coronary angiography was performed showing unobstructed coronary arteries. Acetylcholine (ACh) provocation testing in search of coronary spasm showed diffuse epicardial spasm of the left anterior descending coronary artery (LAD) and focal spasm of the left circumflex coronary artery (LCX), which could be resolved by intracoronary administration of 0.2 mg nitroglycerine (NTG). To evaluate the potential protective effect of NTG, ACh provocation testing was repeated after NTG injection. This rechallenge showed no more epicardial spasm, suggesting that NTG had a protective antispastic effect on the epicardial arteries in this patient. Symptom control in patients with angina due to coronary artery spasm can be challenging as pharmacological agents are often prescribed on a trial and error basis. With this case, we present a novel approach toward a more individualized pharmacotherapy in coronary artery spasm using a modified protocol for invasive coronary spasm testing, which could avoid ineffective treatment trials in such patients.