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Figure 1 Representative coronary arteriograms and electrocardiograms (ECGs) of a 58-year-old female patient having both microvascular and epicardial spasm. Baseline coronary arteriogram of the left coronary artery and ECG were normal. Intracoronary acetylcholine (ACH) 30 µg induced chest pain, ST depression (V4 to V6) and lactate production, but no epicardial spasm. These ischemic symptoms and signs spontaneously subsided in approximately 4 min. Acetylcholine 100 µg provoked a high-degree hyperconstriction (spasm) at the middle portion of the left anterior descending artery (arrowhead), associated with chest pain and ST elevation (I, II, aVL, V3 to V6). Isosorbide dinitrate (ISDN) relieved angina and ischemic ECG changes, and coronary arteriogram showed normal coronary artery.
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