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Acetylcholine is known to determine coronary artery spasm, suggesting a role of vagal activity in triggering the disease.
The diagnosis of cardiac syndrome X was based on the presence of typical exercise-induced angina pectoris that was associated with transient ischaemic ST segment depression (> 1 mm) during the treadmill exercise testing with normal coronary angiogram in the absence of coronary artery spasm as determined by hyperventilation manoeuvre.
1] It was first described by Kounis and Zavras in 1991 [2] as the concurrence of an allergic response with an anaphylactoid or anaphylactic reaction and coronary artery spasm or even myocardial infarction.
Coronary artery spasm as a frequent cause of acute coronary syndrome: The CASPAR (Coronary Artery Spasm in Patients With Acute Coronary Syndrome) Study.
These episodes appeared to result from coronary artery spasm.
Spontaneous multivessel coronary artery spasm can present with a myriad of presentations varying from variant angina to complicated acute myocardial infarction.
Coronary artery spasm with a large heart attack is definitely possible during a period of great stress.
It is well known that coronary artery spasm is an important cause of acute coronary syndrome (ACS).
2 Multiple mechanisms such as coronary artery spasm, catecholamine-mediated impact, direct thermal damage, myocardial ischaemia secondary to arrhythmia, and coronary artery ischaemia as part of a common vascular injury have been suggested to explain the cardiovascular events of lightning injury.
Various aetiological factors including catecholamine-induced cardiotoxicity, multi-vessel epicardial coronary artery spasm, coronary microcirculatory abnormalities and neurogenic-mediated myocardial stunning have been implicated in the pathogenesis of this condition (1).
The type I variant includes patients with normal coronary arteries without predisposing factors for coronary artery disease in whom the acute release of inflammatory mediators induce either coronary artery spasm without increase of cardiac enzymes and troponins or coronary artery spasm progressing to acute myocardial infarction with raised cardiac enzymes and troponins as in our case (8, 9).
3-Year follow-up of patients with coronary artery spasm as cause of acute coronary syndrome: the CASPAR (Coronary Artery Spasm in Patients with Acute Coronary Syndrome) study follow-up.

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