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ESSENTIALS OF DIAGNOSIS

  • Precordial chest pain, often occurring at rest during stress or without known precipitant, relieved rapidly by nitrates.

  • ECG evidence of ischemia during pain, sometimes with ST-segment elevation.

  • Angiographic demonstration of:

    • – No significant obstruction of major coronary vessels.

    • – Coronary spasm that responds to intracoronary nitroglycerin or calcium channel blockers.

GENERAL CONSIDERATIONS

Although most symptoms of myocardial ischemia result from fixed stenosis of the coronary arteries, intraplaque hemorrhage, or thrombosis at the site of lesions, some ischemic events may be precipitated or exacerbated by coronary vasoconstriction.

Spasm of the large coronary arteries with resulting decreased coronary blood flow may occur spontaneously or may be induced by exposure to cold, emotional stress, or vasoconstricting medications, such as ergot-derivative medications. Spasm may occur both in normal and in stenosed coronary arteries. Even MI may occur as a result of spasm in the absence of visible obstructive CHD, although most instances of such coronary spasm occur in the presence of coronary stenosis.

Cocaine can induce myocardial ischemia and infarction by causing coronary artery vasoconstriction or by increasing myocardial energy requirements. It also may contribute to accelerated atherosclerosis and thrombosis. The ischemia in Prinzmetal (variant) angina usually results from coronary vasoconstriction. It tends to involve the right coronary artery and there may be no fixed stenoses. Myocardial ischemia may also occur in patients with normal coronary arteries as a result of disease of the coronary microcirculation or abnormal vascular reactivity. This has been termed “syndrome X.”

CLINICAL FINDINGS

Ischemia may be silent or result in angina pectoris.

Prinzmetal (variant) angina is a clinical syndrome in which chest pain occurs without the usual precipitating factors and is associated with ST-segment elevation rather than depression. It often affects women under 50 years of age. It characteristically occurs in the early morning, awakening patients from sleep, and is apt to be associated with arrhythmias or conduction defects. It may be diagnosed by challenge with ergonovine (a vasoconstrictor), although the results of such provocation are not specific and it entails risk.

TREATMENT

Patients with chest pain associated with ST-segment elevation should undergo coronary arteriography to determine whether fixed stenotic lesions are present. If they are, aggressive medical therapy or revascularization is indicated, since this may represent an unstable phase of the disease. If significant lesions are not seen and spasm is suspected, avoidance of precipitants, such as cigarette smoking and cocaine, is the top priority. Episodes of coronary spasm generally respond well to nitrates, and both nitrates and calcium channel blockers (including long-acting nifedipine, diltiazem, or amlopidine [see Table 11–7]) are effective prophylactically. By allowing unopposed alpha-1-mediated vasoconstriction, beta-blockers have exacerbated coronary vasospasm, but they may have a role in management of patients in whom spasm is associated with fixed stenoses.

WHEN TO REFER

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