Prinzmetal Angina in an Adolescent
Adjunctive Role of Tissue Synchronization Imaging
A previously asymptomatic 17-year-old male athlete presented with acute onset of left-sided chest pain that awakened him from sleep. The pain was described as “crushing,” radiated to the left arm and jaw, and associated with diaphoresis. He was evaluated in the emergency department of our hospital and was found to have an abnormal ECG with ST-segment elevation in the anterolateral leads (Figure 1A). Initial troponin I and creatine kinase-MB (CK-MB) were elevated, 5.7 ng/mL (0 to 1.4) and 29 ng/mL (0 to 7), respectively. Urine toxicity screen was negative, and chest x-ray was unremarkable. Supplemental oxygen, aspirin, and morphine sulfate were administered for cessation of chest pain. Approximately 6 hours after admission, he experienced a second episode of similar chest pain, which did not respond to morphine sulfate but did subside with sublingual nitroglycerin. An echocardiogram at that time confirmed a structurally normal heart but wall motion abnormality by tissue synchronization imaging of the apical segments of the left ventricle, indicative of ischemia in the left anterior descending artery territory (Figure 2A). Emergent cardiac catheterization demonstrated normal coronary arteries by angiography (Figure 3) and no evidence of myocarditis by endomyocardial biopsy and viral serologies.
Successful treatment included nitroglycerin and calcium channel blocker. Cardiac enzymes gradually returned to normal, and follow-up ECG and echocardiogram demonstrated resolution of ST elevation (Figure 1B) and normal segmental wall motion (Figure 2B), respectively. This was a rare case of Prinzmetal (variant) angina in an adolescent.