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Key Features

  • 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, including by Holter monitor

  • No significant obstruction of major coronary vessels

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

Clinical Findings

  • Spasm of the large coronary arteries with resulting decreased coronary blood flow

    • May occur spontaneously or induced by exposure to cold, emotional stress, or vasoconstricting medications and substances, such as ergots and cocaine

    • May occur both in normal and in stenosed coronary arteries

  • Ischemia may be silent or result in angina pectoris or even infarction

  • Prinzmetal (variant) angina

    • Chest pain occurs without the usual precipitating factors and is associated with ST-segment elevation rather than depression

    • The associated ischemia 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

    • Often affects women under 50 years of age

    • Characteristically occurs in the early morning or on awakening from sleep and is associated with arrhythmias or conduction defects

Diagnosis

  • Prinzmetal (variant) angina

    • May be diagnosed by challenge with ergonovine (a vasoconstrictor)

    • However, results of ergonovineprovocation are not specific and it entails risk

  • Patients with chest pain associated with ST-segment elevation should undergo coronary arteriography to determine whether fixed stenotic lesions are present

Treatment

  • If fixed stenotic lesions are present, aggressive medical therapy or revascularization is indicated

  • If significant stenotic lesions are absent and spasm is suspected, avoidance of precipitants such as cigarette smoking and cocaine is the top priority

  • Treatment of coronary vasospasm episodes generally involves nitrates

  • Prophylaxis of episodes can be achieved with both nitrates and calcium channel blockers (including long-acting nifedipine, diltiazem, or amlopidine)

  • β-Blockers

    • Can exacerbate coronary vasospasm by allowing unopposed α1-mediated vasoconstriction

    • May have a role in patients in whom spasm is associated with fixed stenoses

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