A case report of a novel approach to the management of refractory coronary vasospasm.

Background: Coronary vasospasm, or vasospastic angina (VSA), is a clinical entity that can uncommonly occur in the setting of non-obstructive coronary disease. Refractory VSA can be associated with significant adverse cardiovascular events, and a paucity of evidence-based guidelines makes this a challenging clinical scenario for clinicians to treat effectively. Case summary: A 46-year-old male presenting with a 48 h history of epigastric pain with electrocardiogram changes suggestive of left anterior descending artery stenosis and angiography showing no significant obstructive disease. The patient then developed recurrent early morning chest pain with multi-territory ST elevation despite antispasm therapy with repeat angiography and optical coherence tomography showing no evidence of obstructive disease. The patient was diagnosed with idiopathic refractory coronary vasospasm and ultimately managed with corticosteroids and with a wearable cardiac defibrillator. Discussion: The case presented highlights the diagnostics challenges and treatment complexity in managing refractory coronary vasospasm in which our patient experienced a good long-term outcome despite high risk features. Steroids are infrequently used in the management of coronary vasospasm but represent a life-saving treatment option in the setting presumed inflammation. Wearable cardiac defibrillator can be used to both investigate and prevent fatal arrhythmia and should be considered in high-risk coronary vasospasm cohorts.