Sudden Death With Vasospastic Angina That Could Not Be Medically Managed.

Vasospastic angina is characterized by transient coronary artery spasm leading to myocardial ischemia and may present with ST-segment elevation, arrhythmias, syncope, or cardiac arrest. Although typically responsive to vasodilator therapy, a minority of patients develop medically refractory disease with life-threatening complications. We report the case of a man in his 50s who experienced recurrent episodes of chest pain and syncope over several months, each associated with transient anterior ST-segment elevation and occasional dynamic troponin elevation. Coronary angiography and cardiac MRI demonstrated normal coronary anatomy and no structural heart disease. During admission, telemetry captured a prolonged ventricular pause (~10 seconds) secondary to diltiazem. Despite treatment with calcium-channel blockers, long-acting nitrates, and placement of an implantable loop recorder for rhythm surveillance, he continued to experience intermittent vasospastic episodes. Beta-blocker therapy was withdrawn due to concern for heart block, nitrate therapy was progressively uptitrated in the outpatient setting, and a dihydropyridine calcium-channel blocker was introduced. Several days after his final presentation, with chest pain and normal ECG and biomarkers, he suffered an out-of-hospital cardiac arrest due to ventricular fibrillation and died in the intensive care unit. This case illustrates a rare but severe form of vasospastic angina that remained constrained and refractory to escalating medical therapy and ultimately resulted in a fatal ventricular arrhythmia. Early recognition, optimization of vasodilator therapy, and careful rhythm surveillance are essential, but even with appropriate management, some patients remain at risk for sudden cardiac death.