Simultaneous multivessel epicardial coronary artery spasm can mimic severe three-vessel coronary artery disease and was confirmed by near-complete resolution of coronary narrowing following intracoronary nitrate administration, with optical coherence tomography showing only mild non-obstructive atheroma without plaque rupture or thrombus.
Key Findings
Results
Severe, diffuse smooth narrowing of all three major epicardial coronary arteries with critically impaired flow was demonstrated on coronary angiography, initially suggestive of advanced multivessel obstructive disease.
The patient was a man in his early 60s presenting with acute coronary syndrome
The presentation was associated with profound hypoxaemia and systemic prodromal symptoms
Angiographic appearance closely mimicked severe three-vessel coronary artery disease
The narrowing was described as severe and diffuse with critically impaired coronary flow
Results
Intracoronary nitrate administration resulted in rapid and near-complete resolution of the coronary narrowing with restoration of normal flow, confirming the diagnosis of multivessel coronary artery spasm.
Resolution occurred in all three major epicardial coronary arteries following nitrate administration
The response was described as 'rapid and near-complete'
Normal coronary flow was restored after nitrate administration
This pharmacological response was a key diagnostic criterion distinguishing spasm from obstructive atherosclerotic disease
Results
Optical coherence tomography (OCT) confirmed the absence of obstructive atherosclerosis, plaque rupture, or thrombus, establishing multivessel coronary artery spasm as the definitive diagnosis.
OCT demonstrated only mild non-obstructive atheroma
No plaque rupture was identified on OCT imaging
No thrombus was identified on OCT imaging
OCT findings combined with the nitrate response confirmed multivessel coronary artery spasm
Results
The patient developed a small spasm-related myocardial infarction as a complication of the multivessel coronary artery spasm episode.
The myocardial infarction was described as 'small'
The infarction was attributed directly to the coronary artery spasm
This finding illustrates the potential for myocardial injury even in the absence of obstructive coronary artery disease
The patient recovered well following the event
Results
The patient recovered well following optimisation of vasodilator therapy as the primary treatment strategy for multivessel coronary artery spasm.
Recovery was achieved without the need for percutaneous coronary intervention or surgical revascularisation
Treatment was based on optimisation of vasodilator therapy
The favourable outcome followed confirmation of the spasm diagnosis
Simultaneous multivessel epicardial coronary artery spasm is described as 'an uncommon presentation'
What This Means
This case report describes a man in his early 60s who arrived at the hospital with a serious heart attack presentation, low blood oxygen levels, and other systemic symptoms. When doctors performed a coronary angiogram (an X-ray of the heart's arteries), they found that all three major coronary arteries appeared severely narrowed, which looked exactly like advanced blockages from coronary artery disease. However, when a medication called a nitrate was injected directly into the coronary arteries, the narrowing almost completely disappeared within moments, revealing that the arteries were not truly blocked by fatty plaques but were instead in severe spasm — a condition where the muscular walls of the arteries clamp down tightly and restrict blood flow. A detailed imaging technique called optical coherence tomography confirmed there were only mild, non-obstructive deposits in the arteries, with no signs of ruptured plaques or blood clots, definitively diagnosing multivessel coronary artery spasm.
This research suggests that coronary artery spasm affecting all three major heart arteries simultaneously can look virtually indistinguishable from severe multi-vessel coronary artery disease on initial imaging, which has important implications for how patients are diagnosed and treated. Misidentifying this condition could lead to unnecessary and potentially risky procedures such as stenting or bypass surgery, when in reality the correct treatment is medications that relax the arteries (vasodilators). In this case, the patient recovered well after being placed on appropriate vasodilator therapy, avoiding unnecessary interventions.
The case highlights that coronary artery spasm — even affecting multiple vessels at once — is an important cause of heart attacks and severe acute coronary syndromes, and that careful diagnostic testing including the response to intracoronary nitrates and advanced imaging like OCT is crucial to making the correct diagnosis. Early recognition can spare patients from unnecessary procedures and ensure they receive the right medications to prevent future episodes.
Abou Deb G, Sharma A, Fisher M, Albouaini K. (2026). Severe multivessel coronary artery spasm presenting as very high-risk acute coronary syndrome.. BMJ case reports. https://doi.org/10.1136/bcr-2025-271866