Case Report
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Jun 26, 2015; 7(6): 367-372
Published online Jun 26, 2015. doi: 10.4330/wjc.v7.i6.367
Case of angina pectoris at rest and during effort due to coronary spasm and myocardial bridging
Hiroki Teragawa, Yuichi Fujii, Tomohiro Ueda, Daiki Murata, Shuichi Nomura
Hiroki Teragawa, Yuichi Fujii, Tomohiro Ueda, Daiki Murata, Shuichi Nomura, Department of Cardiovascular Medicine, Hiroshima General Hospital of West Japan Railway Company, Higashi-ku, Hiroshima 732-0057, Japan
Author contributions: Teragawa H wrote the manuscript; Fujii Y, Ueda T, Murata D and Nomura S collected data and evaluated the study.
Ethics approval: The study was reviewed and approved by the Hiroshima General Hospital of West Japan Railway Company Institutional Review Board.
Informed consent: Informed consent was obtained from the present patient.
Conflict-of-interest: All the authors have no conflict-of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Hiroki Teragawa, MD, PhD, Department of Cardiovascular Medicine, Hiroshima General Hospital of West Japan Railway Company, 3-1-36 Futabanosato, Higashi-ku, Hiroshima 732-0057, Japan. hiroteraga71@gmail.com
Telephone: +81-82-2621171 Fax: +81-82-2621499
Received: October 30, 2014
Peer-review started: October 30, 2014
First decision: November 14, 2014
Revised: January 16, 2015
Accepted: April 1, 2015
Article in press: April 7, 2015
Published online: June 26, 2015
Abstract

We present a case of a 71-year-old male who had chest symptoms at rest and during effort. He had felt chest oppression during effort for 1 year, and his chest symptoms had recently worsened. One month before admission he felt chest squeezing at rest in the early morning. He presented at our institution to evaluate his chest symptoms. Electrocardiography and echocardiography failed to show any specific changes. Because of the possibility that his chest symptoms were due to myocardial ischemia, he was admitted to our institution for coronary angiography (CAG). An initial CAG showed mild atherosclerotic changes in the proximal segment of the left anterior descending coronary artery (LAD) and mid-segment of the left circumflex coronary artery. Subsequent spasm provocation testing using acetylcholine revealed a bilateral coronary vasospasm, which was relieved after the intracoronary infusion of nitroglycerin. Finally, a CAG showed myocardial bridging (MB) of the mid-distal segments of the LAD. Fractional flow reserve using the intravenous administration of adenosine triphosphate was positive at 0.77, which jumped up to 0.90 through the myocardial bridging segments when the pressure wire was pulled back. Thus, coronary vasospasm and MB might have contributed to his chest symptoms at rest and during effort. Interventional cardiologists should consider the presence of MB as a potential cause of myocardial ischemia.

Keywords: Coronary spasm, Myocardial bridging, Myocardial squeezing, Fractional flow reserve

Core tip: Myocardial bridging (MB), an anomaly in which the myocardium overlies the intramural course of segments of the epicardial coronary arteries, is associated with cardiac events. This may be explained by myocardial ischemia, coronary spasms, and/or mechanical compression of the coronary artery by the MB itself. We encountered a patient with angina pectoris both at rest and during exercise, which was caused by both coronary spasm and MB-induced direct myocardial ischemia. The latter finding was revealed using a pressure wire. MB sometimes causes two vascular characteristics, coronary spasms and direct myocardial ischemia, whose management is quite different.