Coronary Vasospasm Attributable to Fibromuscular Dysplasia

A 32-year-old woman with a 6-year medical history of perimenstrual chest pain and left ventricular systolic impairment after a presumed episode of idiopathic myocarditis presented to the emergency department with 2 hours of severe chest pain and an abnormal ECG with anterolateral ST-segment elevations (Figure 1A). During medical interview, the patient reported the use of cigarettes and cocaine in the past (not for the last 2 years) and very similar symptoms just 2 months earlier. At that time, troponin-I was elevated (12 ng/mL), and subsequent coronary angiogram revealed a dissection of the left circumflex artery, but percutaneous coronary intervention (PCI) could not be performed because of technical complexity, and the patient was commenced on aspirin and clopidogrel.Figure 1. A , Presenting ECG demonstrating anterolateral ST-segment elevations. B , Angiogram of left anterior descending artery displaying a thrombotic occlusion within the middle third of the vessel. C , Angiogram of left circumflex artery displaying a moth-eaten appearance with an angiographically normal artery proximal to the coronary artery, consistent with epicardial coronary fibromuscular dysplasia. D , Confirmation of vasospasm of the left circumflex artery with 25 µg of intracoronary ergonovine, relieved …