Answer - Rhythm Puzzle may 2005

The most striking feature of this ECG is the ST segment elevation and T-wave inversion in leads V1 to V5, aVL and aVR with reciprocal depression in the inferior leads. Findings suggest transmural ischaemia caused by a proximal left anterior descending artery (LAD) lesion. The patient’s history of pain at rest, the ECG during pain and (lack of) findings at coronary angiography together lead to a diagnosis of variant or Prinzmetal angina, in this case electrocardiographically due to proximal LAD spasm. The mainstay of therapy is vasodilative medication (i.e. nitrates and calcium channel blockers) and statins and ACE inhibitors for their effects on the endothelium. Second-line therapy using coronary artery stenting or even brachytherapy has been demonstrated to be of value in drug-refractory cases. Acetylcholine provocation confirmed the diagnosis in this patient, when proximal LAD spasm was observed even on the aforementioned drugs. A stent was placed at the site of spasm during the same procedure. The patient remains free of symptoms after six months of follow-up.

Acknowledgement We are indebted to our colleagues at the Diakonessenhuis Utrecht for this ECG and patient referral.