Published online Jun 26, 2015. doi: 10.4330/wjc.v7.i6.367
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
Processing time: 238 Days and 6.1 Hours
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.
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.