458 Romanian Journal of Cardiology | Vol. 29, No. 3, 2019 CASE PRESENTATION Prinzmetal’s angina with multivessel spasm successfully treated by using two different types of calcium channel blockers Anda Ciobanu 1 , Radu Stavaru 1 , Oana Mirea 1,2 , Petre Ciobanu 3 , Ruxandra Deliu 1 , Octavian Istratoaie 1,2 , Ionut Donoiu 1,2 , Constantin Militaru 1,2 Contact address: Ionut Donoiu Department of Cardiology, University of Medicine and Pharmacy, 2 nd Petru Rares Street, 200349, Craiova, Romania. E-mail address: ionut.donoiu@umfcv.ro 1 Department of Cardiology, County Clinical Emergency Hospital, Craiova, Romania 2 Department of Cardiology, University of Medicine and Pharmacy, Craiova, Romania 3 Department of Cardiology, „Filantropia” Hospital, Craiova, Romania Abstract: Prinzmetal’s angina is characterized by recurrent episodes of chest pain which occur during rest or sleep, asso- ciated with transient elevation of the ST segment on the electrocardiogram. The underlying mechanism is focal or diffuse coronary artery spasm that can affect one or multiple coronary artery sites simultaneously or consecutively. We report the case of a 53-year-old woman with persistent angina which presented with multivessel spasm recorded during coronary angiography without provocation test. The symptomatology of the patient was effectively relieved by combining two calcium channel blockers with a selective inhibitor of phosphodiesterase–3 and a long-lasting nitrate. Keywords: Prinzmetal angina, coronary artery spasm, treatment. Rezumat: Angina Prinzmetal se caracterizează prin episoade recurente de durere toracică care apar în repaus sau în somn, asociate cu supradenivelarea tranzitorie a segmentului ST pe electrocardiogramă. Mecanismul care stă la baza apariţiei anginei este spasmul arterei coronare focal sau difuz care poate afecta una sau mai multe zone ale arterei coronare simultan sau consecutiv. Prezentăm cazul unei femei de 53 de ani cu angină persistentă prezentată cu spasm multivascular înregistrat în timpul angiografiei coronariene fără teste de provocare. Simptomatologia pacientei a fost controlată prin combinarea a două blocante ale canalelor de calciu cu un inhibitor selectiv al fosfodiesterazei–3 şi un nitrat cu efect de lungă durată. Cuvinte cheie: Angina Prinzmetal, spasm coronarian, tratament. CASE PRESENTATION A 53-year-old woman presented to the emergency de- partment for repeated episodes of constrictive chest pain with irradiation at the submandibular level, 2-3 minutes in duration, occurring during sleep, in case of emotional stress or small physical exertion. She had suffered from the anginal attacks for 4 years, but in the previous month, episodes increased in frequency and appeared during mild exertion, as well. Coronary angiography was performed three years prior, when a severe spasm of the right coronary artery was trigge- red by contrast injection (Figure 1, A–D). At that point, the patient was treated with Verapamil 240 mg/ day, Isosorbide dinitrate 20 mg bid, Atorvastatin 40 mg/day, Aspirin 100 mg/day, Trimetazidine 35 mg bid. Other clinical history included recent menopause and INTRODUCTION Typical angina is characterized by recurrent attacks of chest pain, caused by exertion, and relieved by rest or by administration of nitroglycerin. In 1959, Myron Prinzmetal and his colleagues first described an atypi- cal form of angina, which they named ’variant angina’ 1 . Chest pain in variant angina is not caused by physi- cal exercise, it almost always occurs at rest or during sleep, and it is usually associated with transient ST seg- ment elevation on the electrocardiogram. Even thou- gh it is uncommon, Prinzmetal’s angina has important implications for patient’s quality of life, morbidity and cardiac mortality, being associated with potentially lethal complications, such as ventricular tachycardia, ventricular fibrillation, advanced atrioventricular block and asystole 2,3 .