Refractory Multivessel Coronary Artery Spasm Unresponsive to Renal Sympathetic Denervation, with Recurrent Transient ST-Segment Elevation and an Episode of Accelerated Idioventricular Rhythm: A Case Report

Background and Clinical Significance: Multivessel coronary artery spasm (CAS) is an uncommon, high-risk form of vasospastic angina that can produce transient ST-segment elevation mimicking acute myocardial infarction. Evidence to guide management when calcium channel blockers and nitrates fail is scarce, and renal sympathetic denervation (RSD) has been reported in very few patients; Case Presentation: A 53-year-old man with hypertension, type 2 diabetes, and dyslipidemia presented with nocturnal chest pain and inferior ST-segment elevation. Coronary angiography showed severe spontaneous spasm of the right coronary and left anterior descending arteries that resolved completely with intracoronary nitrate; the coronary arteries were otherwise angiographically normal. High-sensitivity cardiac troponin I remained below 10 ng/L (reference 0–34 ng/L), and echocardiography was normal, fulfilling the criteria for definite vasospastic angina without myocardial infarction. The same two-vessel spasm was documented at a second angiogram three months later. Despite maximally tolerated dual calcium channel blockade, nitrates, and statin therapy, he required more than ten further admissions. A self-terminating accelerated idioventricular rhythm lasting about two minutes was recorded. No syncope or malignant arrhythmia occurred, and an electrophysiology review found no current indication for an implantable cardioverter–defibrillator. Radiofrequency RSD was performed off-label for refractory symptoms without complications, but at six months, his symptoms and admissions were unchanged; Conclusions: Our case highlights the diagnostic and therapeutic difficulties in refractory CAS. Accelerated idioventricular rhythm after relief of spasm is a reperfusion rhythm and does not by itself indicate device therapy. In this patient, RSD did not control refractory multivessel CAS, a negative observation that adds to the very limited evidence on autonomic modulation in this setting.