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Prinzmetal's angina; variant angina; coronary vasospasm

Etiology: - coronary vasospasm Epidemiology: 1) 50% of patients with acute coronary syndrome without coronary artery occlusion (by angiography) 2) young women with migraine headaches [5] 3) often occurs in cigarette smokers Pathology: 1) often occurs at a site of an insignificant coronary plaque 2) a majority of patients with variant angina have angiographically significant CAD Clinical manifestations: 1) pain that is not precipitated by cardiac work, is of longer duration, is usually more severe 2) frequently occurs at night in bed. Laboratory: -> no elevation of CK MB or troponin-I Special laboratory: - electrocardiogram: a) ST segment depression b) unusual ECG manifestations including ST segment elevation in leads that are normally depressed in typical angina (ECG leads V1-V4) [6] - resolution of ST segment elevation with nitroglycerin [6] Radiology: - coronary angiography a) transient vasospasm occuring spontaneously or b) following provocative stimuli - intravenous ergonovine - intracoronary acetylcholine - hyperventilation Complications: myocardial infarction Management: 1) acute attacks a) sublingual nitroglycerin b) short-acting nifedipine 2) chronic management a) long-acting nitrates b) long-acting Ca+2 channel antagonists c) beta blockers of little value d) prazosin may be useful 3) surgical revascularization if severe discrete obstructive lesions

General

angina pectoris vasospasm chronic heart disease

References

  1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1374
  3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 90-91
  4. Ong P et al. Coronary artery spasm as a frequent cause of acute coronary syndrome: The CASPAR (Coronary Artery Spasm in Patients With Acute Coronary Syndrome) study. J Am Coll Cardiol 2008 Aug 12; 52:523. PMID: 18687244 - Pepine CJ. Provoked coronary spasm and acute coronary syndromes. J Am Coll Cardiol 2008 Aug 12; 52:528. PMID: 18687245
  5. Medical Knowledge Self Assessment Program (MKSAP) 14, American College of Physicians, Philadelphia 2006
  6. NEJM Knowledge+ - de Luna AB, Cygankiewicz I, Baranchuk A et al Prinzmetal angina: ECG changes and clinical considerations: a consensus paper. Ann Noninvasive Electrocardiol. 2014 Sep;19(5):442-53. PMID: 25262663 PMCID: PMC6932094 Free PMC article. Review.