Erosion-like plaque image during coronary vasospasm

A 58-year-old male with hypertension, diabetes mellitus, and a history of smoking was admitted following a four-week history of oppressive chest pain at rest, with episodes lasting up to 20 minutes. His electrocardiogram and serial cardiac biomarkers were within normal limits. However, transthoracic echocardiography revealed hypokinesia in the basal septal and inferior wall regions. Coronary angiography showed mild atheromatosis in the left coronary artery without significant lesions. The right coronary artery (RCA) (Figure 1A, Moving image 1) demonstrated mild irregularities, along with a moderate lesion in the distal segment. Optical coherence tomography (OCT) revealed a fibrolipidic plaque without evidence of rupture or thrombus formation but with macrophage infiltration and images suggestive of layered plaque (Figure 1B, Figure 1C, Moving image 1). A vasospasm test with acetylcholine was subsequently performed. Following the administration of 20 μg of intracoronary acetylcholine, the patient experienced angina with ST-segment elevation, accompanied by the development of a significant stenosis in the distal RCA and an intermediate stenosis in the proximal segment (Figure 1D,