A 72-year-old man with old inferior myocardial infarction and hepatocellular carcinoma presented with left-side and right-side shoulder pain on effort during the daytime and was referred to our department. His electrocardiogram (ECG) showed no ischemic ST-T changes. However, his serum troponin I was 466.2 pg/mL (normal range, ≤34.2 pg/mL). ECG-gated computed tomography showed a thickened arterial wall of the mid-left anterior descending (LAD) coronary artery with moderate stenosis and late enhancement (Figure A–C, white arrows). Invasive coronary angiography demonstrated moderate stenosis at the same position (Figure D, white arrows). The fractional flow reserve of the LAD stenosis was 0.73, and the coronary flow reserve and index of microcirculatory resistance were 3 and 7, respectively. An acetylcholine provocation test was performed because of the elevation of troponin I. The occlusion was induced at the segment with coronary artery wall thickening (Figure E, white arrows). ST elevation on precordial leads and chest pain were detected, but shoulder pain was not detected. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography showed increased 18F-FDG uptake in the thickened LAD (Figure F, white arrows), but no other abnormality suggesting immunoglobulin-4 (IgG-4)-related disease was detected. His IgG-4 level was 431 mg/dL (normal range, 11–121 mg/dL). Therefore, he was diagnosed with coronary arteritis-inducing effort angina due to IgG-4-related disease.1 Several vasodilators had controlled his symptoms well and his hepatic cancer was endstage; therefore, immunosuppression therapy or coronary intervention was not performed. To the best of our knowledge, this is the first report of drug-induced vasospasm associated with IgG4-related coronary arteritis.
Sources of Funding
This work was supported by the JSPS KAKENHI Grant Number JP23K11891.
Disclosure
Y.K. is a member of Circulation Reports’ Editorial Team.
