Objective: The case refers to a rare cases of a vasospastic angina, at first misinterpreted as ST elevation myocardial infarction, associated with a severe conduction disturbance due to ischemia provoked by the coronary spasm. The main debate in our case is whether the permanent pacemaker was necessary or a conservative strategy consisting in pharmacological treatment and close follow-up would have been an adequate approach. Case presentation: A 50-year-old woman presented for intense retrosternal pain that had awaken her at night, followed immediately by syncope. On arrival to the emergency department she was asymptomatic, with no abnormal findings on the ECG and negative troponin. While there, she repeted the symptoms, the ECG revealed ST-segment elevation in the inferior leads and bradycardia. The patient was then referred to a tertiary hospital for primary PCI, subsequent she was trans-ferred to our hospital. During the second night in our coronary unit she complained of intense retrosternal pain associated with a near syncope, with rapid relief of symptoms and complete resolution of ECG changes after receiving sublingual nitroglycerine. The data led to the diagnosis of a vasospastic angina associated with complete AV block. Coronary angiography showed small atheromatous plaques of the left main, left anterior descending and right coronary arteries and a normal left circumflex artery. The patient was diagnosed with ST elevation myocardial infarction with spontaneous reperfusion and transferred to our hospital. On admission, physical examination was unremarkable. Laboratory test revealed a mild alteration of the glomerular filtration rate. Serial troponin assays were negative. During the second night in our coronary unit she repeted the symptoms, the ECG revealed complete AV block with a heart rate of 35 bpm and 4 mm ST-segment elevation in DII, DIII and aVF with reciprocal changes in V1-V4, all of them solved after receiving sublingual nitroglycerine. Pharmacological therapy was adjusted and the patient remained free of symptoms during hospitalization. She received a dual chamber pacemaker with manager ventricular pacing to minimize the need for stimulation. Three months later, the patient reported three short episodes of retrosternal pain of reduced intensity, without syncope recurrences. Pacemaker interrogation revealed only one episode of second degree type 2 heart block, with 2:1 AV conduction.
Conclusions: In patients with vasospastic angina associating life-threatening conduction disturbances esta-blishing the correct diagnosis and optimal treatment is challenging. However, in patients with syncope due to severe bradycardia, the implantation of a permanent pacemaker seems to be a reasonable approach. In all other case reports addressing this issue found in literature, the indication for permanent pacemaker was made based on clinical judgement. Severe bradyarrhythmias are associated with right coronary artery spasm, whereas malignant tachyarrhythmias appears during left anterior descending artery spasm.Of the triggering factors for coronary spasm in variant angina, smoking is the only documented risk factor, and our pacient was an active smoker.