The thorough review of myocardial infarction with normal coronary arteriograms by Alpert1 suggests that the mechanism in many of these patients is coronary vasospasm. In some, the trigger is cocaine and in others, exercise.
We attended what we thought was effort-induced vasospastic ischemia with and without infarction in a 39-year-old man. Then, 7 years after the first of four such cardiac episodes, cerebral embolism occurred, leading to the discovery of a large, otherwise silent, myxoma in the lower left atrium by echocardiography. We believe that the tumor, which could be seen prolapsing extensively into the mitral orifice, produced myocardial ischemia by impairing diastolic flow during high work loads. Removal of the mass was followed by normalization of the stress electrocardiogram and the absence of further symptoms for more than 3 years.
Thus, a neoplastic entity should be considered when coronary arteriograms are found to be normal after myocardial infarction.