Vasospastic (Prinzmetal) angina
Vasospastic (Prinzmetal) angina is angina from transient epicardial coronary artery spasm, causing rest chest pain with transient ST elevation, typically at night or in the early morning. Diagnosis rests on documenting spasm or reversible ST changes, and treatment is calcium channel blockers and nitrates while strictly avoiding non-selective beta-blockers and triggers.
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What this article covers
- Overview
Definition: vasospastic (Prinzmetal or variant) angina is angina caused by transient, focal or diffuse spasm of an epicardial coronary artery, reducing flow independent of fixed obstruction.
- Epidemiology
More common in certain populations (notably higher prevalence in East Asian populations).
- Risk factors
Smoking (the dominant modifiable risk factor).
- Pathophysiology
Coronary smooth muscle hyperreactivity: an exaggerated vasoconstrictor response causes focal or diffuse epicardial spasm.
- Clinical features
Rest angina, typically nocturnal or early morning, often cyclical.
- Differential diagnosis
Obstructive coronary disease and stable angina: exertional chest pain relieved by rest, distinguished by a fixed stenosis on angiography with reproducible exercise-induced ischemia rather than rest spasm (Chronic stable angina).
- Diagnosis
Establish by documenting transient ischemic ST changes during spasm or provoking spasm, with non-obstructive or normal coronaries: the diagnostic basis is capturing transient ST-segment elevation (or…
- Management
First-line, calcium channel blockers and nitrates, and remove triggers: a calcium channel blocker (amlodipine 5 to 10 mg PO daily, or diltiazem 120 to 360 mg PO daily) as the mainstay, with nitrates…
- Complications
Myocardial infarction during severe spasm.
- Prognosis
Generally good with treatment and smoking cessation.
- Prevention
Smoking cessation (the key measure). Avoid stimulants and known triggers (cold, hyperventilation).
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