Unanticipated response to alpha-adrenergic blockade in pulmonary hypertension.

128 COMMUNICATIONS TO THE EDITOR CHEST, 81: 1, JANUARY, 1982 were normal and the blood pressure was 120/70 mm Hg. The apex beat was dyskinetic and he had an apical 4th heart sound. The ECC showed anterior myocardial infarction. He had a graded exercise test using the Bruce protocol; he ran for eight minutes and reached his target heart rate (180 beats/minute) without chest pain or ST segment change. Coronary angiography was performed by the Judkins technique. The left ventricular end-diastolic pressure was 22 mm Hg. The left ventriculogram showed akinesis of the anterior wall and apex and hypokinesis of the septum. The left anterior descending coronary artery was obstructed at its origin and a ghost of the distal artery ifiled from the circumflex and right coronary arteries. The circumflex artery was normal. The first injection into the right coronary artery showed a normal proximal vessel. The catheter tip slid down the artery and the pressure wave form became damped. The catheter tip was removed and reinserted. The patient complained of chest pain without ECC change and during the subsequent injection, the vessel appeared to have a fresh narrowing. After a second injection, the narrowing became more severe (Fig la). The catheter tip was withdrawn, mfedipine (10 mg) was given sublingually, and after four minutes, the pain subsided. There was no change in arterial blood pressure. A further series of right coronary arteriograms in multiple views showed no evidence of narrowing or irregularity of the arterial lumen; the spasm had disappeared (Fig lb).