Prayer-Associated Coronary Vasospasm: A Case Report
Underlined: presenting author
Background
Myocardial infarction with nonobstructive coronary arteries (MINOCA) accounts for approximately 5–10% of acute myocardial infarctions and is more prevalent in women, occurring in about 10–15% of women compared with 3–5% of men. Coronary vasospasm is an underdiagnosed cause of MINOCA, associated with circadian and autonomic influences, and often requires provocative testing for diagnosis.
Case Presentation
A 40-year-old man with dyslipidemia and a strong family history of premature coronary artery disease presented with recurrent angina occurring exclusively during morning prayer, including one episode lasting 30 minutes without spontaneous resolution. Electrocardiography showed no ischemic changes, and troponin peaked at 0.470 ng/mL, consistent with NSTEMI. Echocardiography showed preserved biventricular function. Coronary angiography revealed normal epicardial arteries with mild mid-LAD myocardial bridging and normal filling pressures, consistent with MINOCA, prompting acetylcholine provocation testing.
Results / Findings
Acetylcholine provocation reproduced the patient's typical symptoms, ischemic ECG changes, and severe diffuse mid-to-distal left anterior descending artery spasm, confirming epicardial coronary vasospasm, with complete resolution following intracoronary nitroglycerin. The patient was discharged on a non-dihydropyridine calcium channel blocker and as-needed nitrates, with counseling on cardiovascular risk factor modification.
Discussion & Conclusion
This case highlights coronary vasospasm as an underrecognized cause of MINOCA. Ischemic episodes occurring during morning prayer likely reflect the circadian vulnerability of coronary vasomotor tone, driven by the physiologic surge in sympathetic tone and catecholamine release upon awakening, rather than a prayer-specific mechanism. Early acetylcholine provocation testing and aggressive cardiovascular risk factor modification are essential to establish etiology and prevent recurrent ischemic events.