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Vasospastic Angina
Aka: Vasospastic Angina, Prinzmetal's Angina, Variant Angina, Variant Angina Pectoris, Coronary Artery Vasospasm
- See Also
- Cocaine-Induced Coronary Vasospasm
- Spontaneous Coronary Artery Dissection
- Angina Pectoris
- Angina Diagnosis
- Unstable Angina
- Chest Pain
- Acute Chest Pain Approach
- Cardiac Risk Factors
- TIMI Risk Score
- Bosner Chest Pain Decision Rule
- Acute Coronary Syndrome
- Acute Coronary Syndrome Immediate Management
- Acute Coronary Syndrome Adjunctive Therapy
- High Risk Acute Coronary Syndrome Management
- Moderate Risk Acute Coronary Syndrome Management
- Low Risk Acute Coronary Syndrome Management
- Myocardial Infarction Stabilization
- Serum Cardiac Markers
- Electrocardiogram in Myocardial Infarction
- Echocardiogram in Myocardial Infarction
- Goldman Criteria for ICU Chest Pain Admission
- Pathophysiology
- Focal arterial spasm of a major Coronary Artery
- Typically in the absence of high grade Coronary Artery stenosis
- Mechanisms
- Vascular smooth muscle hyperreactivity to Vasoconstrictors
- Increased vagal tone
- Increased hyperreactivity to sympathetic stimulation
- Endothelial dysfunction
- Comorbid arterial stenosis
- Most arterial lesions are eccentric (75%)
- Considerable vasoactivity in most vessels
- Vasoconstriction occurs at lesion with Exercise
- Paradoxical: vasodilatation would be expected
- Occurs due to passive vasodilation down stream
- May be associated with other vasospastic conditions
- Raynaud's Phenomenon
- Migraine Headache
- Epidemiology
- Age
- More common under age 50 years old
- Race
- More common in Japanese patients than in Caucasian
- Incidence
- Coronary Artery Vasospasm found in 4% of Coronary Artery angiograms in U.S.
- United States however has among lowest Incidence of Coronary Artery Vasospasm
- Risk Factors
- Tobacco Abuse
- Cocaine Abuse
- See Cocaine-Induced Coronary Vasospasm
- Symptoms
- Recurrent episodic Chest Pain consistent with Angina
- Anterior chest discomfort or pressure
- Radiates to neck, jaw, arms as with typical Angina
- Triggers
- Typically occurs at rest without provocation (e.g. without Exercise, not modified by position)
- May be triggered by Hyperventilation, Cocaine, hypersympathetic states (e.g. peak Exercise)
- Timing
- Early morning hours after midnight
- Duration
- Episodes last 5 to 15 minutes
- Characteristics
- Gradual onset and resolution
- Associated symptoms
- Typical Angina related symptoms (Nausea, diaphoresis, Dyspnea)
- Labs
- Obtain typical labs for chest Pain Evaluation
- Serial Troponin
- Magnesium
- Diagnostics
- Electrocardiogram
- Normal between episodes
- ST Segment elevation during vasospastic episode
- Holter Monitor
- May detect episodes of periodic ST Elevation
- Stress Testing
- Evaluate for severe fixed cardiovascular disease
- Coronary Angiography
- Consider in most patients with suspected Variant Angina
- Differential Diagnosis
- ST Elevation Myocardial Infarction (STEMI)
- Unstable Angina
- Microvascular Angina
- Acute Pericarditis
- Stress-Induced Cardiomyopathy (Takotsuba Cardiomyopathy)
- Management: Prevention of vasospasm
- First-Line measures
- Tobacco Cessation
- Calcium Channel Blockers
- Diltiazem 240 to 360 mg orally daily
- Nifedipine
- Verapamil
- Other measures as indicated
- Statins (e.g. Atorvastatin, Simvastatin, Fluvastatin)
- Replace Magnesium in Magnesium deficiency
- Second-Line measures
- Long-Acting Nitroglycerin
- Isosorbide Mononitrate 30-60 mg once daily
- Indicated if refractory to Calcium Channel Blockers
- Risk of nitrate tolerance (Calcium Channel Blockers are preferred)
- Third-Line Measures
- Percutaneous Coronary Intervention (PCI)
- May be indicated in moderate fixed coronary obstruction
- Avoid provocative agents
- Limit Aspirin to low dose
- Higher dose may predispose to vasospasm
- Aspirin 81 mg should be prescribed in atherosclerotic cardiovascular disease
- Avoid non-selective Beta Blockers (e.g. Propranolol)
- Risk of vasospasm
- Avoid other agents associated with vasospasm
- Triptans (e.g. Sumatriptan)
- 5-Fluorouracil
- Complications
- Myocardial Infarction
- Risk of thrombus forming in response to vasospasm
- Arrhythmia
- Ventricular Tachycardia (left Coronary Artery)
- Heart Block (right Coronary Artery)
- May present with Syncope to Cardiac Arrest
- Consider Implantable Cardioverter-Defibrillator (ICD)
- Resources
- EMedicine Coronary Artery Vasospasm
- http://emedicine.medscape.com/article/153943-overview#showall
- References
- Pinto, Beltrame, Crea in Saperia (2015) Variant Angina, UpToDate, Wolters Kluwer (accessed 6/13/2015)