Abstract Body (Do not enter title and authors here): Introduction
Refractory angina (RA) is a challenging and debilitating condition in the presence of myocardial ischemia regardless of a combination of antianginal drugs and revascularization procedures. Among the phenotypes of RA, there is angina in the absence of obstructive coronary disease (ANOCA). Coronary artery fistulas (CAF) are rare connections between coronary arteries and heart chambers or vessels. 3% of CAF drain into the left ventricle (LV), which can lead to the coronary steal phenomenon and angina in the form of ANOCA. We report here under a case of symptomatic chronic coronary syndrome (CCS) and CAF.
Case report
An 85-year-old woman with CCS had angina progression, reaching functional class 3 and frequent need of nitrate use, despite the use of three antianginal drugs. Stress myocardial perfusion scintigraphy showed reversible hypoperfusion in the lateral, inferolateral and inferior LV walls. A coronary angiogram was performed, revealing the absence of obstructions. However, CAF for the LV was identified around the ischemic territory. It was decided to start our Alopurinol protocol for RA. A treadmill test was done before and after the treatment to assess time to angina occurrence and ST segment change. After 3 months, there were an improvement in the threshold and intensity of angina (class 2) and reduction in nitrate need. In a new scintigraphy, normalization of perfusion was observed, and a new treadmill test showed reduction of 4.1 minutes for angina occurrence with an increase of 1.7 mets and no difference in ST change.
Discussion
CAF are rare, identified in up to 0.2% of angiograms. They can lead to heart failure (HF), myocardial ischemia and arrhythmias. Treatment is based on the clinic, the patient's age and the hemodynamic significance of the CAF. For adults, one of the indications for CAF occlusion is the presence of myocardial ischemia. However, the association between RA and CAF is rarely described in the literature. In the present report, we illustrate the case of an octogenarian with RA, ANOCA and FAC who, before considering interventional treatment, underwent medical optimization with excellent response and improvement in cardiac perfusion and exercise tolerance.
Conclusion
In the scenario of RA and ANOCA, a combination of different antianginal drugs can promote symptoms control and improvement of myocardial perfusion and exercise performance, even in the face of uncommon causes such as the one here reported.