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Background: A man in his fifties with hypertension and no other previous health problems was admitted to the hospital after frequent episodes of retrosternal squeezing chest pain, and an episode of syncope. A recent computer tomography coronary angiography demonstrated normal coronary arteries with no atherosclerosis., Case Presentation: During admission, the patient developed several episodes of chest pain lasting five to fifteen minutes followed by non-sustained ventricular tachycardia, and initially no ST elevation in the electrocardiogram (ECG). He had normal findings on ECG and magnetic resonance imaging of the heart. During hospitalisation, ST elevations in the ECG were observed in relation to chest pain. Due to ST elevation, invasive coronary angiography was performed, revealing a suspected culprit lesion in the left anterior descending artery, treated with percutaneous coronary intervention (PCI). Despite PCI, he had persistent episodes of chest pain with ST elevation and non-sustained ventricular tachycardia. Vasospastic angina was suspected., Interpretation: The clinical presentation is classical for vasospastic angina. After treatment with calcium channel blocker together with long-acting nitrate, there were no new episodes of chest pain or non-sustained ventricular tachycardia. Because of non-sustained ventricular tachycardia with haemodynamic instability and syncope, an implantable cardioverter-defibrillator was implanted.

The term unstable coronary syndromes represents a continuum of patients with unstable chest pain with or without small or large acute myocardial infarctions. There is a tendency towards an epidemiological shift to fewer large infarctions with ST elevation in the ECG (STEMI) to increased numbers of small infarctions without ST elevation (nSTEMI). Patients with unstable angina or nSTEMI should start antithrombotic medication with aspirin, heparin and clopidogrel upon arrival in hospital. Patients with medium or high risk of death or cardiac events will benefit from therapy with IIb/IIIa glycoprotein receptor inhibitors and should be referred for coronary angiography within 6-48 hours after arrival. Final therapy with percutaneous coronary intervention or coronary artery bypass surgery is indicated immediately after angiography or within a few days. Close follow-up with respect to epidemiological risk factors, diet, use of medication according to the results of large randomised studies will further reduce mortality and morbidity, in the short as well as the long term.