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Coronary angiography demonstrated severe, diffuse smooth narrowing of all three major epicardial coronary arteries with critically impaired flow, initially suggestive of advanced multivessel disease. Intracoronary nitrate administration resulted in rapid and near-complete resolution of the coronary narrowing with restoration of normal flow. Optical coherence tomography showed only mild non-obstructive atheroma without plaque rupture or thrombus, confirming multivessel coronary artery spasm. The patient developed a small spasm-related myocardial infarction and recovered well following optimisation of vasodilator therapy.<\/jats:p>","DOI":"10.1136\/bcr-2025-271866","type":"journal-article","created":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T10:35:44Z","timestamp":1787740544000},"page":"e271866","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Severe multivessel coronary artery spasm presenting as very high-risk acute coronary syndrome"],"prefix":"10.1136","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-5254-5615","authenticated-orcid":false,"given":"George","family":"Abou Deb","sequence":"first","affiliation":[{"name":"Cardiology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amitkumar","family":"Sharma","sequence":"additional","affiliation":[{"name":"Cardiology, Liverpool University Hospitals 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