Article ID: CR-25-0016
A 77-year-old man with a history of hypertension was referred to Sapporo Cardiovascular Clinic with recurrent chest pain at rest. His electrocardiogram (ECG) showed no abnormal findings (Figure A). A coronary computed tomography angiography (CCTA) was performed after sublingual nitroglycerin (0.3 mg) and intravenous landiolol (0.125 mg/kg) administration. At the end of the landiolol infusion, he experienced chest pain with ST-segment elevation on the ECG monitor (Figure B). His symptoms resolved immediately after sublingual nitroglycerin, and the ST-segment returned to baseline. The CCTA revealed total occlusion of the distal right coronary artery (RCA; Figure C,D) and severe stenosis at the proximal left anterior descending coronary artery (Figure E,F). However, subsequent coronary angiography showed no significant stenosis (Figure G,H). These findings suggest that intravenous landiolol during CCTA induced severe vasospastic angina (VSA) causing transient total RCA occlusion. The patient was started on a calcium channel blocker (CCB) and long-acting nitrate, remaining symptom-free thereafter.
(A) No abnormal ST-segment changes on the baseline electrocardiogram (ECG). (B) ST-segment elevation during computed tomography angiography (CCTA) on the ECG monitor. (C,D) The CCTA reveals total occlusion of the right coronary artery (RCA; red arrows) and contrast enhancement in the distal RCA (blue arrowheads). (E,F) The CCTA shows severe stenosis at the proximal left anterior descending coronary artery (yellow arrow). (G,H) Coronary angiography demonstrates no significant coronary stenosis.
Landiolol, an ultra-short-acting β1-selective blocker, is commonly used to reduce heart rate and minimize motion artifacts during CCTA. To our knowledge, this is the first report of total occlusion of the coronary artery caused by landiolol-induced VSA during the procedure. Notably, CCTA revealed contrast enhancement in the distal RCA, suggesting transient collateral arteries originating from the left coronary artery and prior multiple episodes of VSA. Landiolol is generally safe for most patients as it rarely induces VSA.1 However, for those with suspected severe VSA, the use of CCBs may mitigate the potential risk of landiolol-induced coronary spasm.
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