From the Guidelines
Calcium channel blockers, such as verapamil, are the first-line treatment for coronary angiospasm, with long-acting nitrates added for patients with persistent symptoms, as recommended by the 2023 AHA/ACC/ACCPC/ASPC/NLA/PCNA guideline 1. The primary goal in managing coronary angiospasm is to prevent spasms and reduce symptoms, thereby improving quality of life and reducing morbidity and mortality.
- The treatment approach involves:
- First-line therapy with calcium channel blockers, such as verapamil (40 mg BID uptitrated) 1
- Addition of long-acting nitrates, such as isosorbide mononitrate (10 mg BID), for patients with persistent symptoms 1
- Sublingual nitroglycerin (0.4 mg) for acute attacks
- Lifestyle changes, including smoking cessation and avoidance of triggers like alcohol and cocaine
- The choice of medication and dosage may vary depending on the individual patient's response and tolerance, with regular follow-up essential to monitor medication effectiveness and adjust dosing as needed.
- It is also important to note that beta blockers are contraindicated in patients with coronary angiospasm, as they can precipitate spasm by leaving alpha-mediated vasoconstriction unopposed by beta-mediated vasodilatation, as highlighted in the 2018 expert consensus document 1.
- The 2020 ESC guidelines for the diagnosis and management of chronic coronary syndromes also support the use of calcium channel blockers and long-acting nitrates in patients with epicardial or microcirculatory vasomotor disorders 1.
- Overall, the treatment of coronary angiospasm requires a personalized approach, taking into account the individual patient's symptoms, medical history, and response to treatment, with the goal of improving quality of life and reducing morbidity and mortality.
From the FDA Drug Label
Amlodipine has been demonstrated to block constriction and restore blood flow in coronary arteries and arterioles in response to calcium, potassium epinephrine, serotonin, and thromboxane A2 analog in experimental animal models and in human coronary vessels in vitro This inhibition of coronary spasm is responsible for the effectiveness of amlodipine in vasospastic (Prinzmetal's or variant) angina.
Amlodipine is effective in treating coronary angiospasm, also known as vasospastic angina or Prinzmetal's angina. The medication works by blocking the constriction of coronary arteries and restoring blood flow, which helps to relieve the symptoms of angina.
- Key benefits: Amlodipine has been shown to decrease the frequency of angina attacks and improve exercise tolerance in patients with vasospastic angina.
- Mechanism of action: Amlodipine inhibits the influx of calcium ions into vascular smooth muscle and cardiac muscle, which helps to relax the blood vessels and reduce the frequency of coronary spasms 2.
From the Research
Coronary Angiospasm Medications
- Calcium channel blockers (CCBs) are the first-line treatment for coronary artery spasm (CAS) 3
- Long-acting nitrates or nicorandil can be added as second-line medications when CAS-related angina symptoms are not well controlled by CCB therapy 3
- Other alternative drugs and interventions for CAS refractory to standard treatments include:
- Rho-kinase inhibitor fasudil
- Anti-adrenergic drugs
- Neural therapies
- Percutaneous coronary interventions 3
- Sublingual administration of short-acting nitrates (nitroglycerin or isosorbide dinitrate) can promptly respond to attacks of variant angina 4
- Calcium antagonists (verapamil or diltiazem) can be given in rare cases resistant to sublingual nitrates 4
- Nonspecific vasodilators, such as calcium channel blocking agents and nitrates, are the mainstay of pharmacologic treatment of coronary artery spasm 4
- Selecting the right CCBs can give the best clinical practice, with options including:
- Diltiazem: decreases angina and increases quality of life, but may cause atrioventricular block and recurrent angina 5
- Nifedipine: decreases vasospastic angina, but may cause excessive drop in BP and increase heart rate 5
- Amlodipine: decreases vasospastic angina, but further studies are needed 5
- Benidipine: shows a statistically significant better prognostic effect on MACE than amlodipine, nifedipine, or diltiazem 6
- Calcium channel blockers are protective against vasospastic angina and treatment with Ca channel blockers provides a better prognosis of VSA 6
- The calcium channel blocking drugs (nifedipine, verapamil, and diltiazem) are an important adjunct to treatment of typical exertional angina and are the treatment of choice for angina due to coronary artery spasm 7