2021 Volume 85 Issue 4 Pages 398-
A 65-year-old woman was referred for coronary computed tomography angiography (CCTA) because of chest pain during exertion and at rest with a circadian variation. Before the imaging examination, 0.3 mg of nitroglycerin was administered. During the CT examination, the patient had no symptoms. CCTA demonstrated significant narrowing with a non-calcified plaque in the left anterior descending artery (LAD) (Figure A,B-a–c). The CT-derived fractional flow reserve (FFRCT) at the distal LAD was 0.74 (Figure C). We evaluated coronary angiography (CAG), followed by ergonovine provocation test and invasive FFR. A coronary spasm occurred at the site corresponding to the stenosis detected by CCTA (Figure E,F). CAG after intracoronary nitroglycerin infusion demonstrated moderate angiographic stenosis in the LAD, and the FFR was 0.86 (Figure F,F). Based on these findings, she was diagnosed with coronary spastic angina. Follow-up CCTA at 1 year demonstrated improvement of the stenosis severity (Figure H,I-d–f).
(A) Baseline angiographic view and (B) multiplanar reconstruction with (a–c) cross-sectional images and (C) computed tomography-derived fractional flow reserve (FFR). (D) Control coronary angiography (CAG) followed by (E) ergonovine provocation test and (F) CAG after nitroglycerin with (G) invasive FFR. (H) Follow-up angiographic view and (I) multiplanar reconstruction with (e–f) cross-sectional images. The arrowhead indicates the middle of the left anterior descending artery.
In this case, although other functional tests for ischemia were not performed, FFRCT, which has high diagnostic accuracy,1 revealed hemodynamically significant stenosis apparently suitable for percutaneous coronary intervention. However, to utilize FFRCT in daily practice, it must be interpreted in conjunction with the clinical context because coronary spasm could modify the results of FFRCT.
No conflicts of interest. N.O. is a member of Circulation Journal’s Editorial Team.
