Coronary Vasospasm and Myopericarditis Presenting as ST-Segment Elevation Myocardial Infarction During Immune Checkpoint Inhibitor Therapy

Background: Immune checkpoint inhibitors (ICIs) are associated with rare but potentially fatal immune-related adverse events, including myocarditis, vasculitis, and hypophysitis. Case Summary: A 53-year-old man with metastatic clear-cell renal cell carcinoma receiving ipilimumab and nivolumab presented with a clinical picture suggestive of acute coronary syndrome. Coronary angiography showed severe triple-vessel disease without a culprit lesion; repeat angiography demonstrated resolution of coronary lesions, consistent with vasospasm. Cardiac magnetic resonance confirmed ICI-associated myocarditis. Concurrent hypophysitis causing secondary adrenal insufficiency was diagnosed. The patient improved with corticosteroids, with full recovery of cardiac function. Discussion: This case illustrates a rare treatable quadrad of immune-related adverse events—coronary vasospasm, myocarditis, pericarditis, and hypophysitis—and highlights coronary vasospasm as a reversible and underrecognized manifestation of ICI-associated myocarditis. Take-Home Messages: Coronary vasospasm can mimic obstructive coronary disease and should be considered in immune checkpoint inhibitor myocarditis. Multisystem immune-related adverse events, including myocarditis, pericarditis, and hypophysitis, may present simultaneously and require prompt multidisciplinary care.