Exercise-induced vasospastic angina: a case report
Exercise-induced vasospastic angina (VSA) is a relatively uncommon clinical scenario but may be fatal if not appropriately managed. The following case has been reported in the European Heart Journal Case Reports.

A 56-year-old male patient presented with chest oppression on exertion for a 2-week duration. The symptom arose while he was riding a bicycle in the morning but did not arise at rest or on exertion in the afternoon. He was an ex-smoker with a history of hypertension and a family history of sudden death. A resting electrocardiogram (ECG) was normal, and echocardiogram revealed no wall motion abnormalities.

Coronary computed tomography angiography indicated a possible stenotic lesion in the circumflex branch. Thus, hospitalization was arranged, and transcatheter coronary angiography (CAG) was performed. In CAG, there was only mild stenosis with small perfusion area in the obtuse marginal branch. A treadmill exercise test was performed the following day to assess the contribution of cardiac ischaemia to his chest symptom on exertion.

At 10 metabolic equivalents, he suddenly developed chest pain and prominent ST elevation in leads II, III, aVF, and V2–5 was noted on ECG. The test was immediately terminated, and nitrates were administered. The symptom disappeared, and the patient’s ECG normalized, confirming the diagnosis of exercise-induced VSA. Another treadmill exercise test was performed 6 days after vasodilators were started. Even at maximum exercise intensity, neither chest symptoms nor ischaemic changes occurred. The patient was discharged, and the chest symptoms have not returned.

Learning points
• Vasospastic angina (VSA) is an important aetiology of angina that often goes undiagnosed. Vasospastic angina can be associated with major adverse events such as myocardial infarction, ventricular arrhythmia, and sudden cardiac arrest unless correctly diagnosed and appropriately managed.

• Attacks of VSA typically occur at rest between the night and early morning. However, some patients present with predominantly exertional chest pain, resembling effort angina due to sclerotic stenosis. Detailed history taking, particularly regarding diurnal variation in chest symptoms and exercise tolerance, is mandatory.

• Exercise test may help diagnosing exercise-induced VSA. However, caution is required when performing exercise test, because it can cause cardiogenic shock due to severe coronary vasospasm.

• Vasospastic angina can usually be controlled by vasodilators such as calcium antagonists and nitrates. Titration of vasodilators until a negative provocation test is achieved is required.

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