Two Different Mechanisms of Myocardial Ischemia Involving 2 Separate Myocardial Segments in a Patient With Normal Coronary Angiography

A53-year-old woman with no risk factors was admitted toour hospital in December 2006 because of worseningangina and positive exercise stress test. Two months earlier,she had been admitted to another hospital because of prolongedepigastrial pain without radiation, which had subsidedjust before she reached the hospital, that was associated with diagnostic elevation of troponin; she reported 3 episodes of the same pain lasting 5 minutes in the early morning hours over the preceding 3 weeks.this patient presented characteristic features of anginalpain consistent with 2 distinct coronary ischemic mechanismsinvolving 2 separate segments of the ventricular wall.This conclusion is supported by the response to the provocative stressors dipyridamole and methylergometrine.